Chapter 5123:2-7 Intermediate Care Facilities

5123:2-7-01 Intermediate care facilities - definitions.

For the purposes of rules in Chapter 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 a facility as determined by the department to be reasonable, as set forth under paragraph (K) of this rule, and do not include fines paid under sections 5111.35 to 5111.62 , 5111.683 , and 5111.99 of the Revised Code. Unless otherwise enumerated in Chapter 5123:2-7 of the Administrative Code, allowable costs are also determined in accordance with the following reference material, as currently issued and updated, in the following priority:

(1) 42 C.F.R. Chapter IV (October 1, 2005);

(2) The centers for medicare and medicaid services provider reimbursement manual (publication 15-1, available at www.cms.hhs.gov/manuals); and

(3) Generally accepted accounting principles in accordance with standards prescribed by the "American Institute of Certified Public Accountants" (available at www.aicpa.org) in effect on the effective date of this rule.

(B) "Date of licensure," for a facility 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 intermediate care facility 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 intermediate care facility that is included in the facility's certified capacity under Title XIX of the Social Security Act, 49 stat. 620 (1935), 42 U.S.C.A. 301 . Therapeutic or hospital leave days for which payment is made under section 5111.33 of the Revised Code are considered inpatient days proportionate to the percentage of the facility's per resident per day rate paid for those days.

(F) "Intermediate care facility for individuals with intellectual disabilities" (or "intermediate care facility") means an intermediate care facility for the mentally retarded certified as in compliance with applicable standards for the medicaid program by the director of health in accordance with Title XIX of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1396 .

(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 intermediate care facility.

(H) "Provider" means a person or government entity that operates an intermediate care facility under a provider agreement.

(I) "Provider agreement" means a contract between the Ohio office of medical assistance and an operator of an intermediate care facility for the provision of intermediate care facility services under the medical assistance 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(2012) .

(K) "Reasonable" means that a cost is an actual cost that is appropriate and helpful to develop and maintain the operation of patient care facilities and activities, including normal standby costs, and that does not exceed what a prudent buyer pays for a given item or services. 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, as detailed:

(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 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 the following conditions are met:

(a) A 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 intermediate care facilities from outside organizations and are not a basic element of patient care ordinarily furnished directly to patients by the facilities; 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.

(5) 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").

(M) "Relative of owner" means a person who is related to an owner of an intermediate care facility 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) "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 intermediate care facility. Replacement beds may originate from within the licensed structure of an intermediate care facility or from another intermediate care facility. Replacement beds are eligible for the cost of ownership efficiency incentive ceiling which corresponds to the period the beds were replaced.

(O) "Representative" means a person acting on behalf of an individual who is applying for or receiving medical assistance. A representative may be a family member, guardian, attorney, hospital social worker, intermediate care facility social worker, or any other person chosen to act on the individual's behalf.

(P) "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.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-02 Intermediate care facilities - provider agreements.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "Closure" means the discontinuance of the use of the building or part of the building that houses the intermediate care facility, and that results in the relocation of the facility's residents who continue to require intermediate care facility services.

(a) A facility's closure occurs regardless of whether there is a replacement of the facility whereby the operator completely or partially replaces the facility's physical plant through the construction of a new physical plant or the transfer of the facility's license from one physical plant location to another.

(b) Facility closure occurs regardless of whether residents of the closing facility elect to be relocated to the operator's replacement facility or to another intermediate care facility.

(c) A facility closure occurs regardless of action taken by the Ohio department of health related to the facility's certification under Title XIX of the Social Security Act, 79 stat. 286 (1965), 42 U.S.C. 1396 , that may result in the transfer of part of the facility's survey findings to a replacement facility, or related to retention of a license as a residential facility under Chapter 5123. of the Revised Code.

(d) The last effective date of the provider agreement of a closed facility will be the date of the relocation of the last resident.

(2) "Operator" means the individual, partnership, association, trust, corporation, or other legal entity that operates an intermediate care facility.

(3) "Reasonable assurance period" means a certain period of time, determined by the centers for medicare and medicaid services, for which a long-term care facility operator whose provider agreement has been involuntarily terminated is required to operate without recurrence of the deficiencies that were the basis for termination. Participation in the medicare and medicaid programs may resume only following that period. If corrections were made before submission of a new request for participation, the period of compliance before the new request is counted as part of the period.

(4) "Voluntary withdrawal" means the operator elects to voluntarily terminate from the medicaid program.

(B) Each intermediate care facility shall have a medicaid provider agreement with the Ohio office of medical assistance. Execution and maintenance of a provider agreement between the Ohio office of medical assistance and the operator of an intermediate care facility is also contingent upon compliance with requirements set forth in this rule.

(C) An intermediate care facility shall:

(1) Execute the provider agreement in the format provided by the Ohio office of medical assistance.

(2) Apply for and maintain a valid license to operate.

(3) Comply with the provider agreement and all applicable federal, state, and local laws and rules.

(4) Keep records and file cost reports as required by rule 5123:2-7-12 of the Administrative Code.

(5) Open all records relating to the costs of its services for inspection and audit by the department and the Ohio office of medical assistance and otherwise comply with rule 5123:2-7-12 of the Administrative Code.

(6) Supply to the department and the Ohio office of medical assistance such information as the department or the Ohio office of medical assistance requires concerning services to individuals who have applied for or been determined to be eligible for medicaid.

(7) Provide the following necessary information to process records for payment and adjustment:

(a) Submit Ohio office of medical assistance form 09401, "Facility CDJFS Transmittal" (revised April 2011), to the county department of job and family services for any information regarding a specific resident for maintenance of current and accurate records; and

(b) Submit Ohio office of medical assistance form 09400, "Nursing Facility Payment and Adjustment Authorization" (revised October 2012), to the Ohio office of medical assistance to initiate, terminate, or adjust medicaid payment for a specific resident as required.

(8) Permit access to the facility and its records for inspection by the department, the Ohio office of medical assistance, 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.

(9) In the case of a change of operator as defined in section 5111.65 of the Revised Code, adhere to the following procedures.

(a) The exiting operator or owner and entering operator must provide a written notice to the department and the Ohio office of medical assistance, as provided in section 5111.67 of the Revised Code, at least forty-five days prior to the effective date of any actions that constitute a change of operator for the intermediate care facility, but at least ninety days if residents are to be relocated. An exiting operator that does not give proper notice is subject to the penalties specified in section 5111.28 of the Revised Code.

(b) The entering operator must submit documentation of any transaction (e.g., sales agreement, contract, or lease) as requested by the department or the Ohio office of medical assistance to determine whether a change of operator has occurred as specified in section 5111.67 of the Revised Code.

(c) The entering operator shall submit an application for participation in the medicaid program and a written statement of intent to abide by rules of the department and the Ohio office of medical assistance, the provisions of the assigned provider agreement, and any existing centers for medicare and medicaid services form CMS-2567, "Statement of Deficiencies and Plan of Correction" (revised February 1999), submitted by the exiting operator.

(d) An entering operator is subject to the same survey findings as the exiting operator unless the entering operator does not accept assignment of the exiting operator's provider agreement. Refusal to accept assignment results in termination of certification on the last day of the exiting operator's participation in medicaid. An entering operator who refuses assignment may reapply for medicaid participation and must undergo a complete initial certification survey by the Ohio department of health. There may be gaps in medicaid coverage at the facility.

(10) 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 Public Law 101-336 (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, creed, national origin, or disability.

(11) Provide notice to the department within five 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" or faxed to (614) 466-0652.

(12) Provide the department, the Ohio office of medical assistance, the resident or guardian, and anyone designated by the resident or guardian written notice at least ninety days prior to a closure or voluntary withdrawal from the medicaid program. An intermediate care facility that does not issue the proper notice is subject to the penalties specified in section 5111.28 of the Revised Code.

(D) An intermediate care facility shall not:

(1) Charge fees for the application process of a medicaid individual or applicant.

(2) Charge a medicaid individual an admission fee.

(3) Charge a medicaid individual an advance deposit.

(4) Directly bill its residents for or directly pass through to its residents the franchise permit fee.

(5) Require a third party to accept personal responsibility for paying the facility charges out of his or her own funds. However, the facility may require a representative who has legal access to an individual's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the individual's income or resources if the individual's medicaid application is denied and if the individual's cost of care is not being paid by medicare or another third-party payor. A third-party guarantee is not the same as a third-party payor (i.e., an insurance company), and this provision does not preclude the facility from obtaining information about medicare and medicaid eligibility or the availability of private insurance. The prohibition against third-party guarantees applies to all individuals and prospective individuals in all intermediate care facilities regardless of payment source. This provision does not prohibit a third party from voluntarily making payment on behalf of an individual.

(E) Effective dates of provider agreements

(1) Effective dates of initial provider agreements generally are assigned by the state survey agency 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 1, 2010).

(F) Conditional provider agreements and cancellation clauses

(1) If the state survey agency determines that an intermediate care facility is in substantial compliance with medicaid standards but has deficiencies that must be corrected, the Ohio office of medical assistance may execute a conditional provider agreement for a term of up to twelve full calendar months, subject to an automatic cancellation clause.

(2) The intermediate care facility must correct deficiencies within sixty days following the scheduled date of correction as established by the state survey agency.

(3) If deficiencies are corrected before the cancellation date, the state survey agency may rescind the cancellation notice, and shall notify the department and the Ohio office of medical assistance in writing of its decision.

(4) If deficiencies are not corrected before the cancellation date, the state survey agency may propose termination of the provider agreement.

(5) If deficiencies are not corrected, the Ohio office of medical assistance may cancel the provider agreement in accordance with section 5111.06 of the Revised Code, unless one of the following occurs:

(a) The state survey agency finds that all required corrections have been made and notifies the department and the Ohio office of medical assistance; or

(b) The state survey agency determines that substantial progress has been made in carrying out a plan of correction that has been submitted to and accepted by the state survey agency.

(G) At the request of the department or upon its own initiative, the Ohio office of medical assistance may terminate, suspend, or not enter into the provider agreement upon thirty days written notice to the provider for violations of Chapter 5111. of the Revised Code; Chapters 5101:3-1, 5101:3-3, and 5123:2-7 of the Administrative Code; and if applicable, subject to Chapter 119. of the Revised Code.

(1) In accordance with section 5111.22 of the Revised Code, a provider agreement may be terminated, denied, or not renewed if the Ohio office of medical assistance determines such an agreement is not in the best interests of the state or medicaid recipients. Best interests include, but are not limited to:

(a) The provider has not fully and accurately disclosed information as required by the provider agreement or any rule contained in division 5101:3 or 5123:2 of the Administrative Code;

(b) The provider has failed to abide by or to have the capacity to comply with the terms and conditions of the provider agreement and/or rules and regulations promulgated by the department or the Ohio office of medical assistance;

(c) The provider has been found liable by a court for negligent performance of professional duties;

(d) The provider has failed to file cost reports as required by rule 5123:2-7-12 of the Administrative Code;

(e) The provider has made false statements or has altered records, documents, or charts. Alteration does not include properly documented correction of records;

(f) The provider has failed to cooperate or provide requested records or documentation for purposes of an audit or review of any provider activity by any federal, state, or local agency;

(g) The provider has been found in violation of section 504 of the Rehabilitation Act of 1973, the Civil Rights Act of 1964, or Public Law 101-336 (the Americans with Disabilities Act of 1990) in relation to the employment of individuals, the provision of services, or the purchase of goods and services;

(h) The attorney general, auditor of state, or any board, bureau, commission, or agency has recommended termination of the provider agreement where the reason for the request bears a reasonable relationship to the administration of the medicaid program or the integrity of state and/or federal funds;

(i) The provider has violated the prohibition against billing medicaid residents for covered services or factoring as found in rule 5101:3-1-13.1 or 5101:3-1-23 of the Administrative Code;

(j) The facility has been found by the Ohio department of health during a survey of the facility to have an emergency that is the result of a determination that there is noncompliance at the condition of participation level that constitutes immediate jeopardy; and

(k) The provider fails to pay the full amount of a franchise permit fee pursuant to section 5112.341 of the Revised Code.

(2) The Ohio office of medical assistance shall terminate, deny, or not renew a provider agreement when any of the situations set forth in division (D) of section 5111.06 of the Revised Code occur.

(3) Notices and termination orders shall comply with provisions set forth in section 5111.06 of the Revised Code.

(H) The county department of job and family services shall use the Ohio office of medical assistance form 09401, "Facility CDJFS Transmittal" (revised April 2011), to communicate information regarding a specific individual.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-03 Intermediate care facilities - institutions eligible to participate in medicaid.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "Certification" means the process by which the state survey agency certifies its findings to the federal centers for medicare and medicaid services or the Ohio office of medical assistance 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" mean beds that are counted in a provider facility that meets medicaid standards. A count of facility beds may differ depending on whether the count is used for certification, licensure, eligibility for medicaid payment formulas, eligibility for waivers, or other purposes.

(3) "Distinct part" means a portion of an institution or institutional complex that is certified to provide intermediate care facility services. A distinct part shall be physically distinguishable from the larger institution and fiscally separate for cost reporting purposes. A distinct part must meet the requirements of 42 C.F.R. 440.150(1994) .

(4) "Facility" means the entity subject to certification and approval in order for the provider to be approved for medicaid payment. A facility may be an entire institution or may be a distinct part of an institution.

(5) "Intermediate care facility services" means those services provided to eligible individuals requiring a level of care and active treatment as set forth and defined in rule 5101:3-3-07 of the Administrative Code and that are available in facilities certified as intermediate care facilities by the Ohio department of health or by the state survey agency of another state.

(B) Requirements for participation

To participate in the Ohio medicaid program and receive payment for intermediate care facility services provided to eligible residents, operators shall meet all of the following requirements:

(1) Operate a facility that meets the licensure, registration, and other applicable state standards as set forth in this rule; and

(2) Operate a facility certified by the Ohio department of health or by the state survey agency of another state as being in compliance with applicable federal regulations for medicaid participation as an intermediate care facility with a minimum of four intermediate care facility certified beds, as set forth in this rule; and

(3) Operate a facility for which the provider has a medicaid provider agreement with the Ohio office of medical assistance.

(C) Qualified types of Ohio intermediate care facilities

To be eligible for certification a facility shall qualify as one of the following:

(1) A residential facility licensed by the department in accordance with section 5123.19 of the Revised Code and rules adopted pursuant to Chapter 5123. of the Revised Code, with an operator who has received development approval to operate the residential facility as an intermediate care facility under one of the following conditions:

(a) An operator has requested a new residential facility license and obtained development approval from the department pursuant to rule 5123:2-3-26 of the Administrative Code to operate the facility as an intermediate care facility; or

(b) An operator of an existing residential facility who has received development approval to operate a facility other than an intermediate care facility, and has submitted a new request for development approval that specifies the plan to modify the type or source of funding for the facility, and has received development approval from the department pursuant to rule 5123:2-3-26 of the Administrative Code to operate the facility as an intermediate care facility.

(2) As described in section 5123.192 of the Revised Code, a nursing home or portion of a nursing home licensed by the Ohio department of health that holds beds initially certified as intermediate care facility beds before June 30, 1987, that continue to be certified as intermediate care facility beds.

(3) A county home, county nursing home, or district home operated in compliance with Chapter 5155. of the Revised Code that was certified as an intermediate care facility before January 20, 2005.

(D) Certification of intermediate care facilities and beds subject to certification survey

(1) Certification

A facility's certification as an intermediate care facility by the Ohio department of health or by the state survey agency of another state governs the types of services the facility may provide.

(2) Provider agreements

A provider agreement with an Ohio intermediate care facility shall include any part of the facility that meets standards for certification of compliance with federal and state laws for participation in the medicaid program.

(3) Emergency services

(a) Waiver of licensed capacity.

(i) To accommodate persons in emergency need of services, the department may issue to the operator of a licensed residential facility a waiver of licensed capacity.

(ii) A waiver of licensed capacity is time-limited and temporarily permits the operator to exceed the maximum number of licensed beds.

(b) Institutional respite care.

(i) A waiver of licensed capacity may be made specifically in order to provide institutional respite care as a prior authorized service to persons enrolled in a home and community based services waiver in accordance with division 5101:3 of the Administrative Code.

(ii) Beds designated for institutional respite care for persons enrolled in home and community-based services waivers shall not be included in the provider agreement.

(4) Beds subject to certification survey

(a) All beds in a medicaid-participating intermediate care facility that are not designated for institutional respite care for persons enrolled in a home and community-based services waiver shall be surveyed to determine compliance with the applicable certification standards.

(b) If the beds are certifiable, they shall be included in the provider agreement.

(c) Beds authorized through a waiver of residential facility licensed capacity in accordance with rule 5123:2-3-26 of the Administrative Code that are used to provide intermediate care facility services shall be included in the provider agreement.

(d) The only other basis for allowing nonparticipation of a portion of an Ohio intermediate care facility is certification of noncompliance by the Ohio department of health.

(E) Requirements for out-of-state providers of intermediate care facility services

(1) To participate in the Ohio medicaid program and receive payment for intermediate care facility services to eligible Ohio residents, an operator of a facility located outside Ohio shall meet all of the following requirements in its state of origin:

(a) The operator of the facility shall hold a valid state-required license, registration, or equivalent from the respective state that specifies the level(s) of care the facility is qualified to provide; and

(b) The operator of the facility shall hold a valid and current medicaid provider agreement from the respective state as an intermediate care facility provider type.

(2) Additionally, out-of-state providers shall meet the following Ohio requirements:

(a) The operator of the facility shall have a current, completed, and signed Ohio office of medical assistance form 03623 on file with the Ohio office of medical assistance; and

(b) The operator of the facility shall obtain resident-specific and date-specific prior authorization in accordance with rule 5101:3-1-11 of the Administrative Code.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-04 Intermediate care facilities - payment during the Ohio office of medical assistance administrative appeals process for termination of a provider agreement.

(A) When the Ohio office of medical assistance 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 intermediate care facility 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 (B) of this rule.

(B) Payment may be provided up to thirty days following the effective date of termination of an intermediate care facility 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:

(1) Payment is for residents admitted to the intermediate care facility before the effective date of termination; and

(2) The intermediate care facility 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.

(C) When the Ohio office of medical assistance acts under instructions from the United States department of health and human services, payment ends on the termination date specified by that agency.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-05 Intermediate care facilities - payment during the state survey agency's administrative appeals process for termination or non-renewal of medicaid certification.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "Effective date of termination" means the date set by the state survey agency or the United States department of health and human services for the termination of certification.

(2) "Informal reconsideration" is the process by which intermediate care facilities may refute in writing, prior to the termination or non-renewal of medicaid certification, the state survey agency's findings on which the termination or non-renewal is based. The facility 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. The facility may or may not choose to utilize informal reconsideration.

(B) When medicaid certification is either terminated or not renewed, the Ohio office of medical assistance must terminate the medicaid provider agreement.

(C) In addition to or in conjunction with the appeals process, the intermediate care facility 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 state survey agency'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 state survey agency 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 the following:

(a) The date of issuance of a final order of adjudication that upholds the state survey agency's termination or non-renewal action; or

(b) The one hundred twentieth day after the effective date of termination of the intermediate care facility's provider agreement.

(2) Payment may be provided up to an additional thirty days following either the cessation of payment on the one hundred twentieth 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 intermediate care facility before the effective date of termination or non-renewal; and

(b) The intermediate care facility cooperates with the state, local, and federal entities in the effort to transfer residents to other facilities or community programs that can meet the residents' needs.

(E) When the Ohio office of medical assistance acts under instructions from the United States department of health and human services, payment ends on the termination date specified by that agency.

(F) When the state survey agency certifies that there is jeopardy to residents' health and safety by issuing an order under Chapter 5111. of the Revised Code, or when it fails to certify that there is no jeopardy, payment will end on the effective date of termination.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-06 Intermediate care facilities - level of care review process.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "Form 03697" means the Ohio office of medical assistance form 03697, "Level of Care Assessment" (revised April 2003).

(2) "Individual" means a medicaid recipient or person with pending medicaid eligibility who is making application to an intermediate care facility, or who resides in an intermediate care facility, or is applying for home and community-based services waiver enrollment.

(3) "Level of care review," as used in this rule, is an assessment of an individual's physical, mental, habilitative, and social/emotional needs to determine whether the individual requires services available in an intermediate care facility. Level of care review is conducted pursuant to paragraph 1902 (a)(30)(A) of the Social Security Act, 42 U.S.C. 1396a(1999) , and are those activities necessary to safeguard against unnecessary utilization. The evaluation of an individual's level of care needs determines the appropriately certified facility type for which medicaid vendor payment can be made. Except as provided in paragraph (C) of this rule, vendor payment can be initiated to an intermediate care facility only when the applicant is determined by the department to need the level of care according to the criteria specified in rule 5101:3-3-07 of the Administrative Code.

(4) "Physician" means a doctor of medicine or osteopathy who is licensed to practice medicine in the state of Ohio.

(5) "Psychologist" means a degreed psychologist who has been licensed by the Ohio board of psychology to practice psychology in the state of Ohio.

(B) Level of care review is required for individuals in the following situations:

(1) Hospitalized individuals who are not currently residents of an intermediate care facility who are applying for intermediate care facility placement.

(2) Hospitalized individuals who are current residents of an intermediate care facility who are seeking admission to a different intermediate care facility.

(3) Individuals seeking readmission to an intermediate care facility after exhausting available paid hospital leave days.

(4) Individuals who are current residents of an intermediate care facility who are seeking admission to a different intermediate care facility.

(5) Individuals who are not currently residents of an intermediate care facility who are seeking admission to an intermediate care facility from community living arrangements.

(6) Individuals who were on paid leave days, are not in a hospital setting, and who have exhausted their paid leave days, who are seeking readmission to an intermediate care facility.

(7) Current residents of an intermediate care facility who are requesting medicaid reimbursement of their stay at the intermediate care facility.

(8) Individuals applying for home and community-based services waiver services.

(C) Under the circumstances in paragraphs (C)(1), (C)(2), and (C)(3) of this rule, vendor payment shall be continued or reinstated when a change in institutional setting is sought.

(1) Current residents of an intermediate care facility receiving medicaid vendor payment who wish to transfer to another intermediate care facility must submit a completed form 03697, not later than the day of transfer to the new intermediate care facility, as specified in paragraphs (D)(1) and (D)(2) of this rule to initiate reimbursement in the new intermediate care facility effective from the date of admission.

(a) Vendor payment to the new intermediate care facility will be authorized back to the date of the individual's admission to the facility. The department shall enter the level of care determination and date into the client registry information system-enhanced to allow for vendor payment. If the department determines that the individual is no longer in need of the level of care, the department shall notify the recipient and the intermediate care facility of the adverse determination and the department's intent to terminate vendor payment. The notice shall set forth the recipient's hearing rights and the time frames within which they must be exercised.

(b) If a hearing request is received in response to the notice specified in paragraph (C)(1)(a) of this rule within time frames specified in division 5101:6 of the Administrative Code that require the continuation of benefits, authorization for payment will be continued pending the issuance of a state hearing decision.

(c) If the individual does not submit a hearing request within the time frame specified in paragraph (C)(1)(b) of this rule, vendor payment will automatically terminate on the date specified in the notice advising the recipient of the department's intent to terminate vendor payment.

(2) Hospitalized individuals who are current residents of an intermediate care facility and are seeking admission to a different intermediate care facility, must meet the requirements in paragraphs (C)(1)(a), (C)(1)(b), and (C)(1)(c) of this rule in order to have vendor payment authorized from the date of admission. These requirements must be met regardless of whether they have exhausted paid leave days.

(3) Hospitalized individuals who are seeking readmission to the same intermediate care facility after exhaustion of paid leave days may be readmitted to that intermediate care facility regardless of the results of the level of care determination if, not later than the date of readmission, the recipient submits a completed form 03697 to initiate reimbursement effective from the date of readmission. If the level of care determination does not match the certification of the facility as specified in paragraph (A)(3) of this rule, the following procedures will apply:

(a) Vendor payment to the intermediate care facility will be authorized back to the date of the individual's admission to the facility. The department shall enter the level of care determination and date into the client registry information system-enhanced to allow for vendor payment. If the department determines that the individual is no longer in need of the level of care, the department shall notify the recipient and the intermediate care facility of the adverse determination and the department's intent to terminate vendor payment. The notice shall set forth the recipient's hearing rights and the time frames within which they must be exercised.

(b) If a hearing request is received in response to the notice specified in paragraph (C)(3)(a) of this rule within the time frames specified in division 5101:6 of the Administrative Code that require the continuation of benefits, authorization for payment will be continued pending the issuance of a state hearing decision.

(c) If the individual does not submit a hearing request within the time frame specified in paragraph (C)(3)(b) of this rule, vendor payment will automatically terminate on the date specified in the notice advising the recipient of the department's intent to terminate vendor payment.

(D) In order to obtain a level of care determination, a form 03697 or an alternative form specified by the department, which has been appropriately completed, accurately reflects the individual's current mental and physical condition, and is certified by a physician must be submitted to the department for review.

(1) The form 03697 or alternative form must include the following components and/or attachments:

(a) Individual's name; medicaid number; date of original admission to the facility, if applicable; current address; name and address of residence if current residence is a licensed or certified residential setting or hospital; and county where the individual's medicaid case is active.

(b) A comprehensive medical, social, and psychological evaluation of the individual. The psychological evaluation must be made before admission, but not more than three months before admission. Each evaluation must include:

(i) Diagnosis, including medical, psychiatric, and developmental diagnoses, including dates of onset, if the date of onset is significant in determining whether the individual has a developmental disability;

(ii) Summary of medical, social, and developmental findings;

(iii) Medical and social family history;

(iv) Mental and physical functional capacity;

(v) Prognoses;

(vi) Kinds of services needed including medical treatments, medications, and other professional medical services;

(vii) Evaluation of the resources available in the home, family, and community; and

(viii) A physician's certification of the individual's need for intermediate care facility services made at the time of admission, or if the individual applies for medicaid while a resident of an intermediate care facility, prior to the initiation of vendor payment.

(2) The entity (i.e., county department of job and family services, hospital, or intermediate care facility) submitting the level of care request must ensure that all required components are included before submission.

(a) Following receipt of the form 03697, the department shall make a determination of whether the form 03697 is sufficiently complete to perform the level of care review. If the form 03697 is not complete, the department shall notify, in writing, the recipient, the contact person indicated on the form 03697, and the intermediate care facility or any other entity responsible for the submission of the form 03697, that additional documentation is necessary in order to complete the level of care review. This notice shall specify the additional documentation that is needed and shall indicate that the individual or another entity has twenty days from the date the department mails the notice to submit additional documentation or the form 03697 will be denied for incompleteness with no level of care authorized. In the event an individual or other entity is not able to complete form 03697 in the time specified, the department shall, upon good cause, grant one extension of no more than five days when an extension is requested by the recipient or other entity.

(b) If the form 03697 is complete upon receipt by the department, or, if within the periods specified in paragraph (D)(2)(a) of this rule, the recipient submits the required documentation, the department shall issue a level of care determination within sixty days. A level of care determination will be issued pursuant to rules 5101:3-3-05 and 5101:3-3-07 of the Administrative Code.

(3) A request for level of care will not be denied by the department for the reason that the individual does not need intermediate care facility services until a registered nurse or a qualified intellectual disability professional conducts a face-to-face assessment of the individual, reviews the medical records that accurately reflect the individual's condition for the time period in which payment is being requested, makes a reasonable effort to contact the individual's physician, and investigates and documents alternative community resources including resources available in the home and family which may be available to meet the needs of the individual.

(E) Level of care review process

(1) The department shall review the application submitted for the individual and enter the level of care determination into the client registry information system-enhanced.

(2) Authorization of payment to an intermediate care facility shall correspond with the effective date of the level of care determination specified in the client registry information system-enhanced. This date shall be:

(a) The date of admission to the intermediate care facility if it is within thirty days of the physician's signature; or

(b) A date other than that specified in paragraph (E)(2)(a) of this rule. This alternative date may be authorized only upon receipt of a letter which contains a credible explanation for the delay from the originator of the level of care request. If the request is to backdate the level of care more than thirty days from the physician's signature, the physician must verify the continuing accuracy of the information and need for inpatient care by either adding a statement to that effect on the form 03697 or by attaching a separate letter of explanation.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-07 Intermediate care facilities - resource assessment notice.

(A) General The Ohio office of medical assistance form 04080, "Medicaid Resource Assessment Notice" (revised October 2005), shall conform to all conditions set forth in rule 5101:1-39-35 of the Administrative Code.

(B) Notification

(1) All intermediate care facilities shall furnish written notice at the time of admission to all individuals with a spouse living in the community of the individual's right to have a resource assessment performed by the county department of job and family services. This includes individuals who, at the time of admission, are eligible for the medicare program, or who are covered by a private third party payer.

(2) The intermediate care facility shall do all of the following:

(a) Give a copy of the resource assessment notice to the resident's family member, legal guardian, or authorized agent; and

(b) Send a copy of the signed resource assessment notice to the county department of job and family services within five working days; and

(c) Post an unsigned copy of the resource assessment notice in a prominent, publicly accessible place within the facility.

(C) Record retention

An intermediate care facility shall keep a signed copy of the resource assessment notice in a resident's record as long as he or she is a resident of the facility. This copy shall be made available upon request to the department, the Ohio office of medical assistance, the county department of job and family services, and the Ohio department of health.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-08 Intermediate care facilities - coverage of bed-hold days for medical necessity and other limited absences.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "Home and community-based services" means services furnished under the provisions of rule 5101:3-1-06 of the Administrative Code, which enable individuals to live in a community setting rather than in an institutional setting such as an intermediate care facility, a nursing facility, or a hospital.

(2) "Hospitalization" means transfer and admission of a resident to a medical institution as defined in paragraph (A)(11) of this rule.

(3) "Intermediate care facility admission" means the act that allows an individual who was not considered a resident of any Ohio medicaid certified intermediate care facility during the time immediately preceding their current intermediate care facility residence to officially enter a facility to receive intermediate care facility services. This may include former residents of intermediate care facilities who have exhausted their bed-hold days while in the community and/or hospital. An intermediate care facility admission may be a new admission or a return admission after an official discharge. An intermediate care facility admission is distinguished from the readmission of a resident on bed-hold status.

(4) "Intermediate care facility bed-hold day," also referred to as "intermediate care facility leave day," means a day for which a bed is reserved for an intermediate care facility resident through medicaid payment while the resident is temporarily absent from the intermediate care facility for hospitalization, therapeutic leave days, or visitation with friends or relatives. Payment for intermediate care facility bed-hold days may be made only if the resident has the intent and ability to return to the same intermediate care facility. A resident on intermediate care facility bed-hold day status is not considered discharged from the intermediate care facility since the facility is reimbursed to hold the bed while the resident is on temporary leave.

(5) "Intermediate care facility discharge" means the full release of an intermediate care facility resident from the facility, allowing the resident who leaves the facility to no longer be counted in the intermediate care facility's census. Reasons for intermediate care facility discharge include, but are not limited to, the resident's transfer to another facility, exhaustion of intermediate care facility bed-hold days from any pay source, decision to reside in a community-based setting, or death.

(6) "Intermediate care facility occupied day" means one of the following:

(a) A day of admission; or

(b) A day during which a medicaid eligible resident's stay in an intermediate care facility is eight hours or more, and for which the facility receives the full per resident per day payment directly from medicaid in accordance with Chapter 5123:2-7 of the Administrative Code.

(7) "Intermediate care facility readmission" means the status of a resident who is readmitted to the same intermediate care facility following a stay in a hospital to which the resident was sent to receive care, or the status of a resident who returns after a therapeutic program or visit with friends or relatives. An intermediate care facility resident can only be readmitted to a facility if that individual was not officially discharged from the facility during that intermediate care facility stay.

(8) "Intermediate care facility therapeutic leave day" means a day that a resident is temporarily absent from an intermediate care facility with intent and ability to return, and is in a residential setting other than a long-term care facility, hospital, or other entity eligible to receive federal, state, or county funds to maintain a resident, for the purpose of receiving a regimen or program of formal therapeutic services.

(9) "Intermediate care facility transfer" means the events that occur when a person's place of residence changes from one Ohio medicaid certified intermediate care facility to another, with or without an intervening hospital stay. However, when the person has an intervening institution for mental disease admission, or when the person is discharged from an intermediate care facility during a hospital stay due to exhaustion of available intermediate care facility bed-hold days and is admitted to a different intermediate care facility immediately following that hospital stay, the change of residence is not considered an intermediate care facility transfer.

(10) "Institution for mental disease" means a hospital, nursing facility, or other institution of more than sixteen beds that is engaged primarily in the diagnosis, treatment, and care of persons with mental diseases, and that provides medical attention, nursing care, and related services. An institution is determined to be an institution for mental disease when its overall character is that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

(11) "Medical institution" means an institution that meets all of the following criteria:

(a) The institution is organized to provide medical care, including nursing and convalescent care.

(b) The institution has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health care needs of patients on a continuing basis in accordance with accepted standards.

(c) The institution is authorized under state law to provide medical care.

(d) The institution is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. Professional medical and nursing services shall include all of the following:

(i) Adequate and continual medical care and supervision by a physician; and

(ii) Registered nurse or licensed practical nurse supervision and services sufficient to meet nursing care needs; and

(iii) Nurse aide services sufficient to meet nursing care needs; and

(iv) A physician's guidance on the professional aspects of operating the institution.

(12) "Skilled nursing facility" means a nursing facility certified to participate in the medicare program.

(B) Prohibition of preadmission intermediate care facility bed-hold payment (1) The department shall not make payment to reserve a bed for a medicaid-eligible prospective intermediate care facility resident.

(2) An intermediate care facility shall not accept preadmission bed-hold payments from a medicaid-eligible prospective intermediate care facility resident or from any other source on the prospective resident's behalf as a precondition for intermediate care facility admission.

(C) Determination of intermediate care facility bed-hold day or intermediate care facility occupied day

To determine whether a specific day is payable as an intermediate care facility bed-hold day or an intermediate care facility occupied day, the following criteria shall be used:

(1) The day of intermediate care facility admission counts as one occupied day; and

(2) The day of intermediate care facility discharge is not counted as either a bed-hold or an occupied day; and

(3) When intermediate care facility admission and intermediate care facility discharge occur on the same day, the day is considered a day of admission and counts as one occupied day, even if the day is less than eight hours; and

(4) A part of a day in an intermediate care facility that is eight hours or more counts as one occupied day for reimbursement purposes. A day begins at twelve a.m. and ends at eleven fifty-nine p.m.

(D) Limits and reimbursement for intermediate care facility bed-hold days

(1) For a medicaid eligible resident in a certified intermediate care facility, except those described in paragraph (I) of this rule, the department may pay the intermediate care facility to reserve a bed only for as long as the resident has an intermediate care facility level of care determination and intends to return to the same intermediate care facility, but not for more than thirty days in any calendar year unless additional days have been prior authorized by the county department of job and family services as specified in paragraph (E) of this rule.

(2) Reimbursement for intermediate care facility bed-hold days shall be paid at one-hundred per cent of the intermediate care facility provider's per diem rate.

(3) Reimbursement for intermediate care facility bed-hold days may be made for the following reasons:

(a) Hospitalization

Intermediate care facility 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 intermediate care facility is not certified to provide; or

(ii) The day the resident is discharged from the hospital, including discharge resulting in transfer to an intermediate care facility, a nursing facility, or a skilled nursing facility; or

(iii) The day the resident decides to go to another intermediate care facility upon discharge from the hospital and notifies the first intermediate care facility; or

(iv) The day the hospitalized resident dies.

(b) Therapeutic leave days

(i) Any plan to use therapeutic leave days must be approved in advance by the resident's primary physician and documented in the resident's medical record. The documentation shall be available for viewing by the county department of job and family services and the department.

(ii) An intermediate care facility shall make arrangements for the resident to receive required care and services while on approved therapeutic leave, but medicaid shall not pay for care and services that are included in medicaid's continued payments, including but not limited to home health care, personal care services, durable medical equipment, and private duty nursing.

(c) Visits with friends or relatives

(i) Any plan for a limited absence to visit with friends or relatives must be approved in advance by the resident's primary physician or by a qualified intellectual disabilities professional, and must be documented in the resident's medical record or individual habilitation plan. The documentation shall be available for viewing by the county department of job and family services and the department.

(ii) An intermediate care facility shall make arrangements for the resident to receive required care and services while on approved visits, but medicaid shall not pay for care and services that are included in medicaid's continued payments, including but not limited to home health care, personal care services, durable medical equipment, and private duty nursing.

(iii) The number of days per visit is flexible within the maximum intermediate care facility 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 intermediate care facility bed-hold days used shall be considered in evaluating the continuing need of a resident for intermediate care facility care.

(E) Requests for additional intermediate care facility bed-hold days

(1) Additional intermediate care facility bed-hold days beyond the original thirty days in a calendar year require prior authorization.

(2) An intermediate care facility shall submit Ohio office of medical assistance form 09402, "ICF-MR/DD Extended Bed Hold Day(s) Prior Authorization" (revised July 2005), to the county department of job and family services. The form shall be submitted before the original thirty leave days are exhausted if it is apparent that additional leave will be needed. The prior authorization part of this form shall be signed by a qualified intellectual disability professional, a medical director, or a primary physician. The request shall be consistent with the goals of the resident's individual habilitation plan and medical records, and shall include all of the following:

(a) Type of leave requested (i.e., hospitalization, therapeutic leave days, or visits with friends or relatives). If the leave is for a trial visit with friends or relatives, descriptions of both a visitation plan and an evaluation plan must be included; and

(b) Projected dates of absence from the intermediate care facility; and

(c) Projected date of return to the intermediate care facility.

(3) The request for additional intermediate care facility bed-hold days shall be received by the county department of job and family services or postmarked to the county department of job and family services office prior to the requested date of additional leave, except in a case of emergency hospitalization. In the event of emergency hospitalization, prior authorization may be requested after the fact if the request is submitted within one business day of the first day of hospitalization.

(4) The county department of job and family services shall review requests for additional bed-hold days and issue one of the following:

(a) An approval notice, pursuant to rule 5101:6-2-02 of the Administrative Code; or

(b) A denial notice, pursuant to rule 5101:6-2-30 of the Administrative Code; or

(c) A request for additional information.

(5) The county department of job and family services shall review prior authorization requests on a case-by-case basis. Conditions under which prior authorization may be denied include but are not limited to the following:

(a) Trial visits beyond thirty consecutive days; or

(b) Visits with friends or relatives exceeding thirty consecutive days or forty-five total days in a calendar year.

(6) A maximum of thirty additional consecutive intermediate care facility bed-hold days may be authorized per request.

(a) The initial request for an additional thirty consecutive bed-hold days shall be submitted to and reviewed for approval or disapproval by the county department of job and family services.

(b) Subsequent requests for an additional thirty consecutive bed-hold days shall be submitted to the county department of job and family services and reviewed for approval or disapproval by the department.

(7) An approved request for additional bed-hold days is for a particular period of time only. Any unused bed-hold days from an approved request shall not be used at a later time during the calendar year. For example, if a resident receives prior authorization for thirty bed-hold days and only uses fifteen, the remaining fifteen days may not be used at a later date during the calendar year. A new prior authorization request must be submitted if additional bed-hold days are required during that same calendar year.

(8) Intermediate care facility bed-hold days beyond the original thirty days that are used but not prior authorized shall be subject to an adjustment of the facility's vendor payment.

(F) Intermediate care facility readmission after depletion of intermediate care facility bed-hold days

(1) The first available bed means the first unoccupied bed not being held by a resident (regardless of the source of payment) who has elected to make payment to hold that bed.

(2) Intermediate care facility readmission requires that a resident has an intermediate care facility level of care and is eligible for medicaid intermediate care facility services.

(G) Maximum number of intermediate care facility bed-hold days

(1) Medicaid payment for covered intermediate care facility bed-hold days is considered reimbursement for reserving bed space for a resident who intends to return to the same intermediate care facility and is able to do so.

(2) The number of intermediate care facility inpatient days as defined in rule 5123:2-7-01 of the Administrative Code for the calendar year shall not exceed one hundred per cent of available bed days.

(H) Residents eligible for payment of intermediate care facility bed-hold days

(1) Medicaid payment for intermediate care facility bed-hold days is available under the provisions specified in this rule if a resident meets all of the following criteria:

(a) Is eligible for medicaid services and has met the patient liability and financial eligibility requirements stated in rule 5101:1-39-24 of the Administrative Code; and

(b) Requires an intermediate care facility level of care; and

(c) Is not a participant of special medicaid programs or assigned special status as outlined in paragraph (I) of this rule.

(2) If a resident meets all of the criteria in paragraph (H)(1) of this rule, and is pending approval of a medicaid application and requires bed-hold days, medicaid payment shall be made retroactive to the date the resident became medicaid eligible and approved for medicaid vendor payment, through the date the resident returns from a leave or until the maximum number of bed-hold days are exhausted.

(I) Exclusions

Intermediate care facility bed-hold days are not available to medicaid eligible intermediate care facility residents in the following situations:

(1) Hospice

A person enrolled in a medicare or medicaid hospice program is not entitled to medicaid covered intermediate care facility bed-hold days. It is the hospice provider's responsibility to contract with and pay the intermediate care facility provider. Hospice program provisions and criteria are stated in Chapter 5101:3-56 of the Administrative Code; or

(2) Institution for mental disease

A resident over age twenty-one and under age sixty-five who becomes a patient of an institution for mental disease loses medicaid eligibility and is not entitled to intermediate care facility bed-hold days. An intermediate care facility provider shall not receive bed-hold day reimbursement during the period a person is hospitalized in an institution for mental disease. The county department of job and family services shall issue the appropriate notice of medicaid ineligibility as stated in rule 5101:6-2-05 of the Administrative Code; or

(3) Home and community-based services waiver

Intermediate care facility bed-hold days do not apply to a person enrolled in a home and community-based services waiver program who is using the intermediate care facility for short-term respite care as a waiver service. Under the home and community-based services waiver program, a person may not have concurrent active status as both a waiver enrollee and as an intermediate care facility resident approved for intermediate care facility vendor payment. Eligibility criteria for the home and community-based services waiver programs are contained in Chapters 5101:3-12, 5101:3-31, 5101:3-40, 5101:3-41, and 5101:3-42 of the Administrative Code; or

(4) Restricted medicaid coverage

A person who is medicaid eligible but is in a period of restricted medicaid coverage because of an improper transfer of resources is not eligible for intermediate care facility bed-hold days until the period of restricted coverage has been met. The criteria for the determination of restricted medicaid coverage are specified in rule 5101:1-39-07 of the Administrative Code; or

(5) Facility closure and resident relocation

Intermediate care facility bed-hold days are not available to residents who relocate due to a facility's anticipated closure, voluntary withdrawal from participation in the medicaid program, or other events that result in termination of a facility's medicaid provider agreement. No span of bed-hold days shall be approved that ends on a facility's date of closure or termination from participation in the medicaid program.

(J) Compliance

(1) Without limiting such other remedies provided by law for noncompliance with these rules:

(a) The Ohio office of medical assistance may terminate the intermediate care facility's provider agreement; or

(b) The department may require the intermediate care facility to submit and implement a corrective action plan on a schedule specified by the department.

(2) An intermediate care facility shall cooperate with any investigation and shall provide copies of any records requested by the department or the Ohio office of medical assistance.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-09 Intermediate care facilities - personal needs allowance accounts and other resident funds.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "Interest-bearing" means a rate of return equal to or above the passbook savings rate at local banking institutions in the area.

(2) "Intermediate care facility for individuals with intellectual disabilities" (or "intermediate care facility") means an intermediate care facility for the mentally retarded certified as in compliance with applicable standards for the medicaid program by the director of health in accordance with Title XIX of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1396 , other than a state-operated intermediate care facility.

(3) "Letters of administration," also known as "letters testamentary," means court papers allowing a person to take charge of the property of a deceased person in order to distribute it.

(4) "Personal needs allowance" has the same meaning as in rule 5101:1-39-24 of the Administrative Code.

(5) "Personal needs allowance account" means an account or petty cash fund that holds the money of a resident of an intermediate care facility and is managed for the resident by the intermediate care facility.

(6) "Surety bond" means an agreement between the principal (i.e., the intermediate care facility), the surety (i.e., the insurance company), and the obligee (i.e., the resident and/or the department acting on behalf of the resident), wherein the principal and the surety agree to compensate the obligee for any loss of the obligee's funds that the principal holds, safeguards, manages, and accounts for. The purpose of a surety bond is to guarantee that an intermediate care facility will pay a resident, or the department on behalf of the resident, for losses occurring from any failure by the intermediate care facility to hold, safeguard, manage, and account for the resident's funds, including losses occurred as a result of acts of error or negligence, incompetence, or dishonesty. The principal assumes the responsibility to compensate the obligee for the amount of the loss up to the entire amount of the surety bond. This paragraph does not require an intermediate care facility to change the obligee from the Ohio office of medical assistance to the department if the surety bond was in effect on the effective date of this rule unless after that date the intermediate care facility makes a change in the surety bond.

(B) Personal needs allowance account

(1) A medicaid resident who receives care in an intermediate care facility is eligible to retain a personal needs allowance account in the amount set forth in rule 5101:1-39-24 of the Administrative Code for the purchase of items and services of his or her choice in accordance with 42 C.F.R. 483.420(1991) . In addition, an intermediate care facility licensed by the Ohio department of health shall comply with section 3721.15 of the Revised Code.

(2) A personal needs allowance account is the exclusive property of the resident, who may use the funds in the account as he or she chooses to meet personal needs.

(C) Management of personal funds

(1) An intermediate care facility shall 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(1991) . In addition, an intermediate care facility licensed by the Ohio department of health shall comply with section 3721.15 of the Revised Code.

(2) An intermediate care facility shall not require a resident to deposit his or her personal needs allowance funds with the intermediate care facility. However, if a resident requests assistance from the intermediate care facility staff in managing his or her personal needs allowance account, the request shall be in writing.

(3) Upon written request from a resident, an intermediate care facility shall hold, safeguard, manage, and account for the resident's personal needs allowance funds deposited with the intermediate care facility.

(4) Upon written request from a resident, an intermediate care facility shall furnish written information about the resident's account to the resident or the resident's representative.

(5) An intermediate care facility shall explain both verbally and in writing to a resident or the resident's representative that personal needs allowance funds are for the resident to use as he or she chooses. If a representative is the payee for the resident's personal needs allowance account, the representative shall be responsible for ensuring that the money is used to meet the personal needs of the resident.

(D) Deposit of personal needs allowance account funds and interest earned by intermediate care facilities licensed by the Ohio department health

(1) If a resident's personal needs allowance account funds are one hundred dollars or less, an intermediate care facility licensed by the Ohio department of health may deposit the funds in an interest-bearing account, a non-interest-bearing account, or a petty cash fund.

(2) If a resident's personal needs allowance account funds are in excess of one hundred dollars, an intermediate care facility licensed by the Ohio department of health shall deposit the funds in an interest-bearing account (or accounts) that is separate from any of the intermediate care facility's operating accounts within five banking days from the date the balance exceeds one hundred dollars.

(3) An intermediate care facility licensed by the Ohio department of health shall credit any interest earned on a resident's personal needs allowance funds to the resident's personal needs allowance account. If pooled accounts are used, the intermediate care facility shall prorate interest per resident on the basis of actual earnings or end-of-quarter balance.

(4) An intermediate care facility licensed by the Ohio department of health shall not charge a resident a fee for managing the resident's personal needs allowance account. Banks, however, may charge the resident a fee for handling the account.

(E) Accounting and records

(1) An intermediate care facility shall establish and maintain a system that ensures full and complete accounting of each resident's funds.

(2) An intermediate care facility shall not combine a resident's personal needs allowance funds with any of the provider's funds or with the funds of any individual other than another resident of the intermediate care facility.

(3) An intermediate care facility shall furnish a resident with access to petty cash (less than fifty dollars) on an ongoing basis and shall arrange for the resident to access larger funds (fifty dollars or more). The provider shall give the resident a receipt for every transaction.

(4) An intermediate care facility shall obtain a resident's signature upon receipt by the resident of money from his or her personal needs allowance account. If the resident is unable to sign his or her name, he or she shall acknowledge receipt of the money by marking an "X." Two persons shall verify through signature that they have witnessed the resident's action. Personal needs allowance funds shall not be withdrawn or utilized by the intermediate care facility for any purpose other than that requested by the resident to whom the fund belongs.

(5) An intermediate care facility shall maintain a detailed ledger account of revenue and expenses for each personal needs allowance account managed by the intermediate care facility. The ledger account shall meet all of the following criteria:

(a) Specify all funds received by or deposited with the intermediate care facility. For personal needs allowance account funds deposited in banks, monies shall be credited to the resident's bank account within three business days;

(b) Specify the dates and reasons for all expenditures;

(c) Specify at all times the balance due the resident, including interest earned as last reported by the bank to the intermediate care facility; and

(d) Be available to the resident or the resident's representative for review.

(6) Upon request, an intermediate care facility shall furnish receipts to a resident or the resident's representative for purchases made with the resident's personal needs allowance funds.

(7) Within thirty days after the end of the quarter, an intermediate care facility shall furnish a written quarterly statement to each resident or resident's representative of all financial transactions made by the intermediate care facility on the resident's behalf.

(F) Notification of certain balances and transactions that may affect medicaid eligibility

(1) Notice to resident

(a) An intermediate care facility shall give written notification to each resident who receives medicaid benefits and whose personal funds are managed by the intermediate care facility when the amount in the resident's personal needs allowance account reaches two hundred dollars less than the resource limits set forth in rules 5101:1-39-01.1 and 5101:1-39-05 of the Administrative Code.

(b) The notice shall inform the resident that he or she may lose medicaid eligibility if the amount in his or her personal needs allowance account, in addition to the value of his or her other nonexempt resources, reaches his or her resource limit amount.

(c) A copy of the notice shall be retained in the resident's file.

(2) Notice to the county department of job and family services

An intermediate care facility 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 shall apply the excess amount to the routine cost of the resident's intermediate care facility care according to rule 5101:1-38-20 of the Administrative Code.

(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 intermediate care facility shall refer the resident or the resident's representative 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.

(G) Release of funds upon discharge

Upon discharge of a resident, an intermediate care facility shall release all the resident's personal needs allowance account funds, up to and including the resource limit amount.

(H) Conveyance of funds upon death for an intermediate care facility licensed by the Ohio department of health

(1) First thirty days

An intermediate care facility licensed by the Ohio department of health shall not retain the money in a resident's personal needs allowance account beyond thirty days following the resident's death if letters testamentary or letters of administration are issued, or an application for release from administration is filed under section 2113.03 of the Revised Code concerning the resident's estate within that thirty-day period. In these circumstances, the intermediate care facility licensed by the Ohio department of health shall 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. If these conditions for release are not met, the intermediate care facility shall follow paragraph (H)(2) or (H)(3) of this rule.

(2) First sixty days

If, within sixty days after a resident's death, letters testamentary or letters of administration are issued, or an application for release from administration is filed under section 2113.03 of the Revised Code concerning the resident's estate, the intermediate care facility licensed by the Ohio department of health shall 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.

(3) After sixty days

(a) If, within sixty days after a resident's death, letters testamentary or letters of administration concerning the resident's estate are not issued, or an application for release from administration is not filed under section 2113.03 of the Revised Code concerning the resident's estate, and if the resident was a recipient of medicaid benefits, the intermediate care facility licensed by the Ohio department of health shall transfer the resident's personal needs allowance account funds to the Ohio office of medical assistance no earlier than sixty and no later than ninety days after the resident's death, with the exception listed in paragraph (H)(3)(c) of this rule.

(b) Personal needs allowance account funds transferred to the Ohio office of medical assistance shall be paid by check or money order made payable to "Attorney General of Ohio" and shall be accompanied by a completed Ohio office of medical assistance form 09405, "Personal Needs Allowance Account Remittance Notice" (revised July 2005). The payment and completed form 09405 shall be mailed to the Ohio attorney general's office.

(c) If funeral or burial expenses for a deceased resident have not been paid and the only resource left to pay those expenses are 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 shall be used to pay the expenses.

(d) If, sixty-one or more days after a resident dies, letters testamentary or letters of administration are issued, or an application for release from administration under section 2113.03 of the Revised Code is filed concerning the resident's estate, the Ohio office of medical assistance shall transfer the resident's personal needs allowance account funds to the administrator, executor, commissioner, or person who filed the application for release from administration, unless the Ohio office of medical assistance is entitled to recover the money under section 5111.11 of the Revised Code.

(I) Conveyance of funds upon death for an intermediate care facility licensed by the department

For an intermediate care facility licensed by the department, conveyance of funds upon death shall be in accordance with rule 5123:2-3-14 of the Administrative Code.

(J) Financial security for an intermediate care facility licensed by the Ohio department of health

An intermediate care facility licensed by the Ohio department of health shall purchase a surety bond or provide other necessary assurances to the director of the department to ensure the security of all resident funds deposited with and managed by the intermediate care facility.

(1) Surety bond.

(a) A surety bond shall be executed by a licensed surety company pursuant to Chapters 1301., 1341., and 3929. of the Revised Code.

(b) At a minimum, surety bond coverage shall protect at all times the full amount of resident funds deposited with the intermediate care facility, including interest earned and refundable deposit fees.

(c) The surety bond shall provide for repayment of funds lost due to any failure of the intermediate care facility, whether by commission, bankruptcy, omission, or otherwise, to hold, safeguard, manage, and account for resident funds.

(d) Except as provided in paragraph (J)(1)(f) of this rule, the surety bond shall designate either the resident, or the department on behalf of the resident, as the obligee.

(e) If an entity purchases a surety bond that covers more than one of its facilities, the surety bond shall protect the full amount of all resident funds on deposit in all the entity's facilities.

(f) Paragraph (J)(1)(d) of this rule does not require an intermediate care facility to change the obligee from the Ohio office of medical assistance to the department if the surety bond was in effect on the effective date of this rule unless after that date the intermediate care facility makes a change in the surety bond.

(2) Reasonable alternative to the surety bond

An intermediate care facility electing not to purchase a surety bond shall submit a proposal for an alternative to the department for approval. A reasonable alternative to the surety bond shall provide protection equivalent to that afforded by a surety bond. Neither self insurance nor deposit of funds in bank accounts protected by the federal deposit insurance corporation or a similar entity are acceptable alternatives to a surety bond. An acceptable alternative shall meet all of the following criteria:

(a) At a minimum, protect at all times the full amount of resident funds deposited with the intermediate care facility, including interest earned and refundable deposit fees;

(b) Except as provided in paragraph (J)(2)(f) of this rule, designate either the department or the residents of the intermediate care facility as the entity or entities that will collect payment for lost funds;

(c) Guarantee repayment of funds lost due to any failure of the intermediate care facility, whether by commission, bankruptcy, omission, or otherwise, to hold, safeguard, manage, and account for resident funds;

(d) Be managed by a third party unrelated in any other way to the intermediate care facility or its management; and

(e) Not name the intermediate care facility as a beneficiary.

(f) Paragraph (J)(2)(b) of this rule does not require an intermediate care facility to change the designee from the Ohio office of medical assistance to the department if the alternative to the surety bond was in effect on the effective date of this rule unless after that date the intermediate care facility makes a change in the alternative.

(K) Limitations on charges to the personal needs allowance account

(1) An intermediate care facility shall not charge a resident's personal needs allowance account for items and services that the intermediate care facility is required to furnish in order to participate in the medicaid program, and that are included in medicaid payments made to the intermediate care facility.

(2) An intermediate care facility shall inform each medicaid eligible resident of the medicaid program's coverage and limitations.

(3) Items and services that may not be purchased with personal needs allowance account funds include, but are not limited to, the following:

(a) Nursing services;

(b) Dietary services;

(c) Activities programs;

(d) Room and bed 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, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing, 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.

(L) 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, even if the items or services are requested by a physician.

(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 intermediate care facility shall inform the resident that there will be a charge and the amount of the charge.

(3) An intermediate care facility shall not require a resident to request an item or service as a condition for admission to or continued stay in the intermediate care facility.

(M) Items and services that may be charged to the personal needs allowance account

(1) An intermediate care facility 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 intermediate care facility, the resident's personal needs allowance funds may be used as long as a comparable item of reasonable quality is available from the provider at no charge. The intermediate care facility may charge the resident only the difference in cost between the available item and the resident's preferred item.

(2) Items and services that may be charged to a resident's personal needs allowance account include, but are not limited to, the following:

(a) Telephone;

(b) Television or radio for personal use;

(c) Personal comfort items, including smoking materials, notions, novelties, and confections;

(d) Cosmetics and grooming items and services in excess of those for which payment is made under the medicaid program;

(e) Personal reading material;

(f) Stationary or stamps;

(g) Personal clothing;

(h) Specialty laundry services such as dry cleaning, mending, or hand-washing;

(i) Flowers or plants;

(j) Gifts purchased on behalf of a resident;

(k) Non-covered special care services such as privately hired nurses or nurse aides;

(l) Social events or entertainment offered outside the scope of the facility's activities program;

(m) Private rooms, except when therapeutically required for infection control or similar reasons;

(n) Specially prepared or alternative food instead of food generally prepared by the facility; and

(o) Burial plots.

(N) Monitoring The county department of job and family services is responsible for monitoring personal needs allowance accounts. At least once a quarter, a designated county department of job and family services employee shall determine if an intermediate care facility is following the provisions of this rule, and shall 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 account funds by a payee or an intermediate care facility does not, however, reduce the scope or duration of medicaid benefits for a medicaid recipient.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-10 Intermediate care facilities - outlier services for behavioral redirection and medical monitoring.

(A) Purpose

(1) The purpose of this rule is to identify a subpopulation of those persons determined to require an intermediate care facility level of care whose care needs are not adequately measured by the individual assessment form or by the resident assessment classification and case mix payment system described in rule 5123:2-7-20 of the Administrative Code.

(B) For the purposes of this rule, the following definitions shall apply:

(1) "Behavioral phenotype" means the observable or measurable expression of a gene or genes and the heightened probability that a person with a given syndrome will exhibit behavioral or developmental sequelae relative to others without the syndrome.

(2) "Intermediate care facility for behavioral redirection and medical monitoring" means an intermediate care facility approved by the department to deliver outlier services for behavioral redirection and medical monitoring that holds an effective intermediate care facility for behavioral redirection and medical monitoring provider agreement with the Ohio office of medical assistance.

(3) "Individual plan" means a written description of the services to be provided to an individual, developed by an interdisciplinary team that represents the professions, disciplines, or service areas that are relevant to identifying the individual's needs, as described by the comprehensive functional assessments.

(4) "Level of care review" means the evaluation of an individual's physical, mental, and social/emotional status to determine the level of care required to meet the individual's service needs and includes activities necessary to safeguard against unnecessary utilization. Level of care determinations are based upon the criteria regarding the amount and type of services needed by an individual that are set forth in rules in Chapter 5101:3-3 of the Administrative Code. The level of care process is also the mechanism by which the medicaid vendor payment is initiated for non-outlier facilities. For outlier facilities, individuals require written preadmission or continued stay prior authorization approval from the department before vendor payment may be initiated or continued for a time-specific duration.

(5) "Designated outlier coordinator" means a designated department staff member who coordinates the general operations of the intermediate care facility outlier program. This coordinator works with providers of outlier services, the individuals and their representatives requesting and receiving outlier services, other service agencies, and other department staff. This coordinator's duties include, but are not limited to, the following:

(a) Assisting with the initial approval and ongoing monitoring of outlier provider facilities; and

(b) Coordinating the processing of preadmission and continued stay prior authorization requests for individuals; and

(c) Representing the department as a team member on the individual's interdisciplinary team; and

(d) Reviewing assessments, individual plans, day programming plans, staffing plans, and other documents.

(6) "Outlier services" means those clusters of services that have been determined by the department to require reimbursement rates established pursuant to section 5111.258 of the Revised Code when delivered by qualified providers to individuals who have been prior authorized for the receipt of a category of service identified as an outlier service by the department and/or set forth as such in Chapter 5123:2-7 of the Administrative Code.

(7) "Physician" means a doctor of medicine or osteopathy who is licensed to practice medicine.

(8) "Plan of correction" means a corrective action plan prepared by an intermediate care facility in response to deficiencies cited by the state survey agency. The plan shall conform to regulations and guidelines, and shall include 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 facility will assure that compliance will be maintained upon correction.

(9) "Prior authorization assessment for intermediate care facility behavioral redirection and medical monitoring services" means an evaluation to determine if an individual meets the criteria to be served by an intermediate care facility for behavioral redirection and medical monitoring as outlined in paragraphs (C)(3) to (C)(10) of this rule, and shall 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.

(10) "Prior authorization approval for intermediate care facility behavioral redirection and medical monitoring services" means approval obtained by the provider of intermediate care facility behavioral redirection and medical monitoring services from the department on behalf of a specific individual for specific time-limited initial or continued stay periods at an that holds an effective intermediate care facility for behavioral redirection and medical monitoring provider agreement. Prior authorization for intermediate care facility behavioral redirection and medical monitoring services shall be required for the provider to be authorized by the department to receive reimbursement for services rendered to the individual, because payment rates for these services are determined through a contracted rate process in accordance with rule 5101:3-3-17 of the Administrative Code. Reimbursement may be denied for any service not rendered in accordance with rules in Chapters 5101:3-3 and 5123:2-7 of the Administrative Code.

(a) Initial prior authorization for intermediate care facility behavioral redirection and medical monitoring services.

Unless the individual is seeking a change of payer, the prior authorization of payment for intermediate care facility behavioral redirection and medical monitoring services shall occur prior to admission to the intermediate care facility for behavioral redirection and medical monitoring.

(b) Continued stay prior authorization for intermediate care facility behavioral redirection and medical monitoring services.

In the case of requests for continued stay, the prior authorization of payment for intermediate care facility behavioral redirection and medical monitoring services shall occur no later than the final day of the previously authorized intermediate care facility for behavioral redirection and medical monitoring stay.

(11) "Progressive serious medical condition" means an illness, injury, impairment, or physical or mental condition, or a combination of mental and physical conditions, that continues over an extended period of time and involves a regimen of continuing treatment and/or periodic visits/monitoring by a physician, or by a nurse or physician's assistant under direct supervision of a physician. A progressive serious medical condition involves the characteristic signs and symptoms of the condition becoming more prominent by manifesting more frequently or increasing in severity as part of the course of the condition.

(12) "Secondary medical condition" means an additional physical or mental health condition that occurs more frequently among persons having a specific primary progressive serious medical condition.

(C) Individual eligibility criteria To receive prior authorization approval for intermediate care facility behavioral redirection and medical monitoring services, an individual shall meet all the following criteria:

(1) Financial eligibility

The individual shall have been determined by the county department of job and family services to meet the medicaid financial eligibility standards for institutional care; and

(2) Level of care determination

The individual must have obtained a level of care determination from the department within the last thirty days, or, at the time of prior authorization assessment for intermediate care facility behavioral redirection and medical monitoring services, be determined by the department to meet the criteria for a level of care as set forth in rule 5101:3-3-07 of the Administrative Code; and

(3) Presence of progressive developmental disability

The individual shall have either a developmental disability other than an intellectual disability, or have a diagnosis of intellectual disability and have been determined to function at the mild or moderate intellectual level in accordance with standard measurements as recorded in the most current revision of the manual of terminology and classification published by the American association on intellectual disabilities; and

(4) Presence of primary progressive serious medical condition

The individual shall have a primary diagnosis of a progressive serious medical condition other than a mental or physical impairment solely caused by mental illness as defined in division (A) of section 5122.01 of the Revised Code, and other than an intellectual disability, that is generally acknowledged to be associated with:

(a) Behaviors posing a substantial risk of injury to self or others that cannot be eradicated by psychiatric, pharmacologic, neurologic, or behavioral intervention, or combination of interventions; and

(b) Behaviors requiring a restrictive environment to maintain health and safety; and

(5) Presence of secondary medical condition

The individual shall have at least one medical condition other than mental illness or intellectual disability that is a secondary manifestation of the primary progressive serious medical condition listed in paragraph (C)(4) of this rule; and that, without intervention, would threaten the person's medical stability; and

(6) Episode of injury to self or others and continuing risk of injury to self or others

(a) Within the twelve months preceding the initial prior authorization assessment for intermediate care facility behavioral redirection and medical monitoring services, the individual shall have exhibited behavior that is generally acknowledged to be associated with one of the medical conditions described in paragraph (C)(4) or (C)(5) of this rule that resulted in substantial injury to self or others; and

(b) Within the twelve months prior to any continued stay prior authorization assessment for intermediate care facility behavioral redirection and medical monitoring services, the individual shall have exhibited behavior that is generally acknowledged to be associated with one of the medical conditions described in paragraph (C)(4) or (C)(5) of this rule that poses substantial risk of injury to self or others; and

(7) Presence of aberrant motivational behavioral profile

Within the past twelve months, the individual shall have exhibited a consistent pattern of behaviors or frequent episodes that displays the following behavioral profile:

(a) Lacks impulse control; and

(b) Exhibits purposeful, but dysfunctional, goal-directed behavior to obtain or avoid something; and

(c) Makes manipulative threats of harm to self, others, or property to obtain this goal; and

(d) Has the physical capability to carry out the threats; and

(e) Has a history of carrying out the threats and/or currently attempts to carry out the threats; and

(8) Constant monitoring and continual behavioral intervention

For individuals eligible to receive intermediate care facility behavioral redirection and medical monitoring services, reduction in health and safety risks are expected to result from external and continuously required intervention, not from any expected internal gains in insight or impulse control by the individual or elimination of risk through medical treatment of the medical conditions.

(a) The individual shall exhibit behaviors generally acknowledged to be associated with the medical conditions described in paragraph (C)(4) or (C)(5) of this rule that are not expected to be eliminated through the implementation of psychiatric, neurologic, or pharmacologic interventions or combination of interventions, and thus present a continuing need for temporary control through behavioral intervention strategies such as behavioral redirection.

(b) The individual shall require constant staff attention during waking hours for redirection and intervention, and awake staff supervision twenty-four hours a day, seven days a week; and

(9) A substantially restrictive environment

The individual shall have at least one behavioral manifestation generally acknowledged to be associated with the primary medical condition listed in paragraph (C)(4) of this rule, and that requires a substantially restrictive environment to maintain health and safety by eliminating opportunities for the behavior to occur; and

(10) Less restrictive settings ruled out The individual shall not be able to have these behavioral and medical needs met in any setting less restrictive than an intermediate care facility for behavioral redirection and medical monitoring.

(D) Provider eligibility criteria

Prior to enrollment as an intermediate care facility behavioral redirection and medical monitoring service provider, and at regular intervals to be determined subsequent to that enrollment, the department shall determine whether the intermediate care facility behavioral redirection and medical monitoring service provider qualifications are fulfilled through review of documentation of appropriate policies and procedures, on-site visits, and other mechanisms determined to be appropriate by the department. In order to obtain an intermediate care facility behavioral redirection and medical monitoring provider agreement and qualify for enhanced payment for provision of intermediate care facility behavioral redirection and medical monitoring services to prior authorized individuals, a provider shall meet all of the following criteria:

(1) Certified intermediate care facility and consent to oversight

The provider shall be an Ohio medicaid certified intermediate care facility, and shall agree to cooperate with the department's oversight of intermediate care facility behavioral redirection and medical monitoring services; and

(2) Intermediate care facility provider agreement

The provider shall meet the requirements set forth in rule 5123:2-7-02 of the Administrative Code in order to obtain a provider agreement; and

(3) Dedicated facility or discrete unit of facility

Intermediate care facility behavioral redirection and medical monitoring services shall be provided in either a discrete, distinctly identified unit of the intermediate care facility dedicated to the provision of outlier services for persons requiring intermediate care facility behavioral redirection and medical monitoring services, or in a freestanding intermediate care facility.

(a) If the service is delivered in a distinctly identified unit of a larger intermediate care facility, the provider's state licensure process and its medicaid certification process may continue to recognize only one facility, but the Ohio office of medical assistance shall issue separate provider agreements to the outlier and non-outlier units.

(b) Unoccupied certified beds may be moved between the outlier and non-outlier units in accordance with the following:

(i) The department must receive a written request from the provider at least five business days before the selected date of the bed change. 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" or faxed to (614) 466-0652. The department shall issue a written response either approving or denying the request; and

(ii) Approvals may be granted for unoccupied bed moves only once per calendar quarter. More than one bed movement during a calendar quarter may be authorized at the sole discretion of the department; and

(iii) No intermediate care facility shall discharge a resident earlier than is indicated in the resident's treatment plan as a result of a request to move beds from the outlier unit to the non-outlier unit; and

(iv) The intermediate care facility shall meet all requirements set forth in paragraphs (D)(7) and (D)(8) of this rule for beds moved into the outlier unit from the non-outlier unit; and

(4) Licensure survey findings

(a) Within the thirty-six months prior to acceptance by the department as a provider of intermediate care facility behavioral redirection and medical monitoring services, the provider shall:

(i) Have been in full compliance with residential facility licensure standards; or

(ii) Have an approved plan of correction and have not demonstrated a pattern of repeat deficiencies.

(b) New facilities shall not be approved as providers of intermediate care facility behavioral redirection and medical monitoring services until any required licensure plans of correction are implemented; and

(5) Certification survey findings

(a) Within the thirty-six months prior to acceptance as a provider of intermediate care facility behavioral redirection and medical monitoring services, the provider shall:

(i) Have fully met all the standards for medicaid intermediate care facility certification; or

(ii) Have met the medicaid program requirements of a facility for which the state survey agency found deficiencies, have an approved plan of correction from the state survey agency, and have not demonstrated a pattern of repeat deficiencies.

(b) Facilities may not be approved as providers of intermediate care facility behavioral redirection and medical monitoring services until any required certification plans of correction are implemented; and

(6) Physical environment

(a) Single person bedrooms.

Each resident shall have a private bedroom.

(b) Environmental alterations.

Residents who qualify for prior authorization of intermediate care facility behavioral redirection and medical monitoring services are aggressive, assaultive, and/or destructive, and pose significant health or security risks.

(i) Based on the expected care needs of those residents, including residents whose records document that programs incorporating the use of less restrictive environments have been tried systematically and demonstrated to be ineffective, the provider shall make significant environmental alterations that are expected to reduce or eliminate the destructive outcome to people or the environment, or to reduce the need for continual replacement of damaged property.

(ii) Examples of such resident-specific adaptations or modifications may include, but are not limited to, fenced yards, alarm systems, reduced access to kitchens and food supplies, or furnishings that are more difficult to destroy.

(c) Structural modifications.

The provider shall demonstrate the ability to rapidly respond to presented needs for structural changes related to the residents' behaviors; and

(7) Facility staffing

(a) Availability of direct care staff.

(i) Providers shall schedule direct care staff to ensure that adequately trained staff are present and on duty seven days a week, twenty-four hours a day, every day of the year. Staffing shall 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 the resident's individual plan.

(ii) Absences of staff for breaks and meals shall not compromise this requirement.

(b) Management/qualified intellectual disability professional experience.

Staff employed to manage intermediate care facility behavioral redirection and medical monitoring services, including services delivered by a qualified intellectual disability professional, shall have evidence of at least two year's work experience with individuals who have severe behavioral issues.

(c) Staff training.

Staff training programs shall address the specific behavioral and medical domains a staff member must master for a thorough understanding and demonstration of competency in order to meet the intensive needs of residents requiring intermediate care facility behavioral redirection and medical monitoring services. Initial and continuing direct care staff training shall include all of the following:

(i) Orientation to the facility or distinct part unit's status as a provider of intermediate care facility behavioral redirection and medical monitoring services, including the individual eligibility criteria outlined in paragraph (C) of this rule, and the provider eligibility criteria outlined in this paragraph; and

(ii) Information about the disorders/syndromes, behavioral phenotypes, and stages of disease progression affecting the current residents of the intermediate care facility behavioral redirection and medical monitoring provider; and

(iii) Accepted best practices and innovative approaches to meet these resident needs in both behavioral and medical domains; and

(8) Service collaboration and day programming

(a) Prior to approval as a provider of intermediate care facility behavioral redirection and medical monitoring services, the provider shall demonstrate the ability to collaborate with county boards of developmental disabilities and with others to provide service for individuals described in paragraph (C) of this rule.

(b) Prior to any individual's admission to an intermediate care facility for behavioral redirection and medical monitoring, the provider shall arrange for a suitable school or day program for the individual and shall submit the plan for such program to the designated outlier coordinator or other department designee; and

(9) Preliminary evaluation

Prior to an individual's admission, the provider shall 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; and

(10) Transitional plan

(a) Due to the complex and intensive needs of individuals being admitted to an intermediate care for facility behavioral redirection and medical monitoring, the provider shall perform sufficient planning prior to admission in order to ensure that the facility is able to meet an individual's health, safety, and behavioral needs from the day of admission.

(b) The transitional plan shall address major concerns and shall be submitted for review to the designated outlier coordinator or other department designee prior to the individual's admission; and

(11) Initial assessment

Within thirty days after admission, the provider shall 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 in order to supplement the preliminary evaluation described in paragraph (D)(9) of this rule, which was conducted prior to admission; and

(12) Individual plan, team meeting, and quarterly report

(a) Within thirty days of an individual's admission, the facility shall develop and submit to the designated outlier coordinator or other department designee a comprehensive, individual plan. The plan shall be reviewed by the appropriate program staff at least quarterly and revised as necessary.

(b) The facility shall notify the designated outlier coordinator or other department designee at least one week in advance of each full-team meeting, and provide the designated outlier coordinator or other department designee with minutes of the meeting upon request.

(c) The facility shall prepare and provide to the designated outlier coordinator or other department designee a quarterly report in a format approved by the department that summarizes the resident's individual 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. A current copy of the resident's individual plan shall be available to the designated outlier coordinator or other department designee upon request; and.

(13) Discharge plan

(a) Within thirty days after admission, the facility shall develop and submit for approval to the designated outlier coordinator or other department designee a written discharge plan developed by the interdisciplinary team in conjunction with the individual and others concerned with the individual's welfare.

(b) The discharge plan shall include all of the following:

(i) Description of targeted behavioral and medical/health status indicators that would signify the resident could be safely discharged; and

(ii) Recommendations for any counseling and/or training of the individual and family members or interested persons to prepare them for post-discharge care; and

(iii) Evaluation of the likely need for appropriate post-discharge services, the availability of those services, the providers of those services, the payment source for each service, and dates on which notification of the individual's needs and anticipated time frames was or would be made to the providers of those services; and

(14) Reassessment of discharge plan

When periodic reassessment of the discharge plan indicates that an individual's discharge needs have changed, the provider shall submit the results of the reassessments and the revised discharge plan to the designated outlier coordinator or other department designee within five working days following the revision; and

(15) Continued stay denials

If prior authorization is denied during an assessment that was requested for an individual already residing in the intermediate care facility for behavioral redirection and medical monitoring unit, the intermediate care facility shall do both of the following:

(a) Move the individual to the first available intermediate care facility bed that is not in the intermediate care facility for behavioral redirection and medical monitoring unit for as long as intermediate care facility services are needed; and

(b) Until such time as a more appropriate placement can be made, accept payment for the provision of services at the non-outlier intermediate care facility reimbursement rate; and

(16) Contracted rate

(a) Based on materials submitted by the intermediate care facility and the methodology set forth in this rule, the department shall contract with the intermediate care facility to set initial and subsequent rates for intermediate care facility behavioral redirection and medical monitoring services.

(b) With the exception of any specific items that are direct-billed in accordance with rule 5123:2-7-11 of the Administrative Code, the provider shall agree to accept as payment in full the per diem rate established for intermediate care facility behavioral redirection and medical monitoring 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 intermediate care facility behavioral redirection and medical monitoring services.

(E) Prior authorization for services

Payment for intermediate care facility behavioral redirection and medical monitoring services covered by the medicaid program shall be available only upon prior authorization by the department for each individual in accordance with the procedures set forth in this paragraph. These prior authorization procedures are in addition to the level of care review process as set forth in rule 5123:2-7-06 of the Administrative Code.

(1) Submission of initial request

(a) 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" or faxed to (614) 466-0652.

(b) Requests shall be sent to the designated outlier coordinator or other department designee.

(c) A request is considered submitted when it is received by the designated outlier coordinator or other department designee.

(2) Initial request requirements

It is the responsibility of the provider to ensure that all required information is provided to the department as requested. Prior authorization will not be given until all of the initial application requirements set forth in this rule have been met. An initial request for prior authorization of intermediate care facility behavioral redirection and medical monitoring services is considered complete when all of the following requirements have been met:

(a) The Ohio office of medical assistance form 03142, "Prior Authorization" (revised March 2008), has been appropriately completed and submitted; and

(b) The Ohio office of medical assistance form 03697, "Level of Care Assessment" (revised April 2003), or an alternative form specified by the department that accurately reflects the individual's current mental and physical condition and is certified by a physician has been appropriately completed and submitted; and

(c) In accordance with the level of care review process for intermediate care facilities set forth in rule 5123:2-7-06 of the Administrative Code, a level of care determination has been issued in accordance with rule 5101:3-3-07 of the Administrative Code; and a determination regarding the feasibility of community-based care has been made; and

(d) The intermediate care facility for behavioral redirection and medical monitoring has submitted to the designated outlier coordinator the prior authorization request form and supporting documentation exhibiting evidence that the applicant meets criteria listed in paragraphs (C)(3) to (C)(12) of this rule. The provider shall retain a duplicate copy of all submitted documentation. Supporting documentation may include, but is not limited to, the preliminary evaluation, assessments, and individual plan required prior to admission as set forth in paragraph (D) of this rule.

(3) Initial stay assessment

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 intermediate care facility behavioral redirection and medical monitoring services, which may include a face-to-face visit by at least one department representative with the individual and, if applicable, the individual's representative and, to the extent possible, the individual's formal and informal care givers, to review and discuss the individual's care needs and preferences.

(4) Prior authorization determination

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 shall 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 intermediate care facility behavioral redirection and medical monitoring services.

(5) Notice of determination

When the prior authorization request has been processed by the department indicating approval or denial of the request for authorization of reimbursement, notices shall be sent by mail or fax that include all of the determinations made and the individual's state hearing rights, in accordance with Chapter 5101:6-2 of the Administrative Code, to the individual, the individual's legal guardian and/or representative (if any), and the provider. The provider may perform any service(s). However, reimbursement shall be limited to services approved as indicated in the approval letter.

(a) Denial

When a request for prior authorization of reimbursement for intermediate care facility behavioral redirection and medical monitoring services is denied, the department shall issue a notice of medical determination and a right to a state hearing. A copy of this denial notice shall be sent to the the county department of job and family services to be filed in the individual's case record. The notice shall also include an explanation of the reason for the denial.

(b) Approval

When a request for prior authorization of reimbursement for intermediate care facility behavioral redirection and medical monitoring services has been approved, the department shall issue an approval letter that includes an assigned prior authorization number, the number of days for which the intermediate care facility for behavioral redirection and medical monitoring placement is authorized, and the date on which payment is authorized to begin. It also will include the name, location, and phone number of the department staff member who is assigned to monitor the individual's progress in the facility, participate in the individual's interdisciplinary team, and monitor implementation of the individual's discharge plan.

The department shall send a copy of the approval letter to the county department of job and family services to be filed in the individual's case record.

(i) Authorization for initial stay

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 up to a maximum of six months, or up to one hundred eighty-four days. The number of months or days that is prior authorized for each eligible individual shall 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 length of stay in the intermediate care facility for behavioral redirection and medical monitoring unit.

(ii) Authorization for continued stays

Continued stay determinations shall be based on reports from the facility 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 other collaborative 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, continued stays may be approved for maximum increments of six months, up to one hundred eighty-four days.

(6) Discharge

(a) 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 shall be monitored by the department or its designee throughout the individual's stay in the intermediate care facility for behavioral redirection and medical monitoring unit.

(b) Intermediate care facility behavioral redirection and medical monitoring services may be extended beyond the previously approved length of stay if the provider submits a written request to the department proving that it is not possible to implement the individual's discharge plan. Such requests shall be submitted at least one week 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.

(F) Provider agreement addendum

(1) After the department has approved an intermediate care facility operator as a qualified provider of intermediate care facility behavioral redirection and medical monitoring services, the Ohio office of medical assistance form 03642, "Provider Agreement for Behavioral Redirection and Medical Monitoring Outlier Services" (revised July 2007), shall be completed.

(2) The form 03642 shall be completed as part of each subsequent annual provider agreement renewal with the Ohio office of medical assistance, unless the provider chooses to withdraw as a provider of intermediate care facility behavioral redirection and medical monitoring outlier services or is determined by the department to no longer meet the qualifications set forth in paragraph (D) of this rule.

(G) Payment authorization

The payment authorization date shall be one of the following, but shall not be earlier than the effective date of the individual's level of care determination:

(1) The date of admission to the intermediate care facility for behavioral redirection and medical monitoring unit if it is within thirty days of the physician's signature on the Ohio office of medical assistance form 03697, "Level of Care Assessment" (revised April 2003), or an alternative form specified by the department; or

(2) The date of intermediate care facility for behavioral redirection and medical monitoring prior authorization approval, if the individual was already a resident of an intermediate care facility behavioral redirection and medical monitoring but was using another payer source; or

(3) A date other than that specified in paragraph (G)(1) or (G)(2) of this rule. This alternative date may be authorized only upon receipt of a letter by the designated outlier coordinator or other department designee that contains a credible explanation for the delay from the originator of the request for prior authorization of intermediate care facility behavioral redirection and medical monitoring services. If the request is to backdate the level of care and intermediate care facility for behavioral redirection and medical monitoring eligibility determination more than thirty days from the physician's signature, the physician shall verify the continuing accuracy of the information and need for inpatient care either by adding a statement to that effect on the form 03697 or alternative approved form, or by attaching a separate letter of explanation.

(H) Required information In addition to information that must be submitted pursuant to rule 5123:2-7-12 of the Administrative Code, an outlier provider must submit the following:

(1) In the initial year that an intermediate care facility is approved as an outlier provider, the provider must submit, no later than ninety days after the effective date of the outlier provider agreement, each of the following:

(a) The projected cost report budget for the initial year of operation; and

(b) The current calendar year capital expenditure plan, including a detailed asset listing; and

(c) The current calendar year plan for basic staffing patterns, using a format to be approved by the department, that includes the staff schedule by shift, number of staff in each position, staff position descriptions, base wage rates, and a brief explanation of contingencies that may require adjustments to these basic staffing patterns.

(2) The following information must be submitted no later than ninety days after the end of the initial three months of operation as an outlier provider:

(a) A cost report for the period of the initial three months of service; and

(b) Current individual plans for residents to be served in the period for which a rate is being established.

(3) In each calendar year subsequent to the year of the initial contracted rate, the following information must be submitted by the thirty-first of March:

(a) Current individual plans for residents to be served in the period for which a rate is being established; and

(b) The actual year end cost report shall be submitted within the deadline specified in rule 5123:2-7-12 of the Administrative Code. The current calendar year cost report budget shall be submitted by the thirty-first of March of the current calendar year, in conjunction with the previous calendar year's actual cost report; and

(c) For-profit providers shall submit a balance sheet, income statement, and statement of cash flows for the outlier facility relating to the previous calendar year's actual cost report submitted in accordance with paragraph (I)(3)(b) of this rule; and

(d) Not-for-profit providers shall submit a statement of financial position, statement of activities, and statement of cash flows for the outlier facility relating to the previous calendar year's actual cost report submitted in accordance with paragraph (I)(3)(b) of this rule; and

(e) The current calendar year capital expenditure plan, including the detailed asset listing; and

(f) The current calendar year plan for basic staffing patterns, using a format to be approved by the department, that includes the staff schedule by shift, number of staff in each position, staff position descriptions, base wage rates, and a brief explanation of contingencies that may require adjustments to these basic staffing patterns; and

(g) Approved board minutes from the legal entity holding the provider agreement and all other related legal entities for the calendar year covered by the actual cost report submitted in accordance with paragraph (I)(3)(b) of this rule.

(I) Per diem rates

Medicaid per diem rates for outlier providers shall be based upon reasonable and allowable costs using the following method:

(1) There shall be four components of the per diem rate: direct care, indirect care, capital, and other protected (including the franchise permit fee rate).

(a) The direct care per diem shall be determined in accordance with section 5111.23 of the Revised Code. The rate may be increased if deemed necessary by the department based on analysis of historical direct care costs if the provider had previously been a medicaid provider, a comparison of direct care costs and staffing ratios of facilities caring for individuals with similar needs, a comparison of payment rates paid by private insurers and/or other states, and an analysis of the impact on historical costs if there are plans to change the resident mix.

(b) The indirect care per diem shall be determined in accordance with section 5111.241 of the Revised Code. The rate may be increased due to increased expenses deemed necessary by the department for treatment of individuals requiring outlier services.

(c) The capital per diem shall be determined in accordance with section 5111.251 of the Revised Code. Adjustments may be made for special high cost equipment or other capital expenditures deemed by the department to be necessary for treatment of individuals requiring outlier services.

(d) The other protected per diem shall be determined in accordance with section 5111.235 of the Revised Code.

(2) The total prospective rate for intermediate care facilities or discrete units of intermediate care facilities providing outlier services, shall be established by combining the allowable direct care, indirect care, capital, and other protected per diems determined in accordance with paragraphs (I)(1)(a) to (I)(1)(d) of this rule.

(J) Initial and subsequent contracted rates

Intermediate care facilities approved by the department as outlier providers shall receive rates established in accordance with this rule for individuals that have been prior authorized by the department on the first day of the month in which prior authorized outlier services were provided, but no earlier than the first day of the month in which the approved application for an outlier provider agreement was received by the Ohio office of medical assistance.

(1) The department shall establish the initial contracted rate no later than ninety days after the department receives all the required information. The initial contracted rate will be implemented retroactively to the initial date services were provided pursuant to the outlier provider agreement.

(2) In each year subsequent to the year of the initial contracted rate, the contracted rate will be effective for the fiscal year beginning on the first of July and ending on the thirtieth day of June of the following calendar year.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-11 Intermediate care facilities - relationship of other covered medicaid services.

This rule identifies covered services generally available to medicaid recipients and describes the relationship of such services to those provided by an intermediate care facility. Reimbursement of services through the "facility cost report mechanism" referenced in this rule is governed by rule 5123:2-7-12 of the Administrative Code. References to "intermediate care facilities" in paragraphs (A) to (I) of this rule do not include state-operated intermediate care facilities for which reimbursement is made in accordance with rule 5101:3-3-99 of the Administrative Code.

(A) Dental services

All covered dental services provided by licensed dentists are reimbursed directly to the provider of the dental services in accordance with Chapter 5101:3-5 of the Administrative Code. Personal hygiene services provided by facility staff or contracted personnel are reimbursed through the facility cost report mechanism.

(B) 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 reimbursable through the facility 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 5101:3-11 of the Administrative Code.

(C) Medical supplier services

Certain medical supplier services are reimbursable through the facility cost report mechanism and others directly to the medical supply provider as follows:

(1) Items that must be reimbursed through the facility cost report mechanism include:

(a) Costs incurred for "needed medical and program supplies," defined as items that have a very limited life expectancy, such as, atomizers, nebulizers, bed pans, catheters, electric pads, hypodermic needles, syringes, incontinence pads, splints, and disposable ventilator circuits.

(b) Costs incurred for "needed medical equipment" (and repair of such equipment), defined as items that can stand repeated use, are primarily and customarily used to serve a medical purpose, are not useful to a person in the absence of illness or injury, and are appropriate for the use in the facility. Such medical equipment items include hospital beds, wheelchairs, and intermittent positive-pressure breathing machines, except as noted in paragraph (C)(2) of this rule.

(c) Costs of equipment associated with oxygen administration, such as, carts, regulators/humidifiers, cannulas, masks, and demurrage.

(2) Services that are reimbursed directly to the medical supplier provider, in accordance with Chapter 5101:3-10 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 recipient.

(b) "Prostheses," defined as devices that replace all or part of a body organ to prevent or correct physical deformity or malfunction, such as, artificial arms or legs, electro-larynxes, and breast prostheses.

(c) "Orthoses," defined as devices that assist in correcting or strengthening a distorted part, such as, arm braces, hearing aids and batteries, abdominal binders, and corsets.

(d) Contents of oxygen cylinders or tanks, including liquid oxygen, except emergency stand-by oxygen which is reimbursed through the facility cost report mechanism.

(e) Oxygen producing machines (concentrators) for specific use by an individual recipient.

(D) Pharmaceuticals

(1) Over-the-counter drugs not listed in appendix A to rule 5101:3-9-12 of the Administrative Code, for which prior authorization was requested and denied, and nutritional supplements are reimbursable only through the facility cost-report mechanism.

(2) Pharmaceuticals reimbursable directly to the pharmacy provider are subject to the limitations found in Chapter 5101:3-9 of the Administrative Code, the limitations established by the Ohio state board of pharmacy, and the following conditions:

(a) When new prescriptions are necessary following expiration of the last refill, the new prescription may be ordered only after the physician examines the patient.

(b) A copy of all records regarding prescribed drugs for all patients must be retained by the dispensing pharmacy for at least six years. A receipt for drugs delivered to an intermediate care facility must be signed by the facility representative at the time of delivery and a copy retained by the pharmacy.

(E) Physical therapy, occupational therapy, speech therapy, audiology services, psychologist services, and respiratory therapy services

Costs incurred for physical therapy, occupational therapy, speech therapy, audiology services, psychology services and respiratory therapy services provided by licensed therapists or therapy assistants or provided by licensed psychologists or psychology assistants and that are covered for residents of intermediate care facilities either by medicare or medicaid, are reimbursable through the facility cost report mechanism. Reasonable costs for rehabilitative, restorative, or maintenance therapy services rendered to intermediate care facility residents by contracted staff or facility staff and the overhead costs to support the provision of such services are reimbursable through the rate determined in accordance with sections 5111.20 to 5111.33 of the Revised Code. Costs incurred for the services of a licensed psychologist are reimbursable through the facility cost report mechanism. No reimbursement for psychologist services shall be made to a provider other than the intermediate care facility, or a community mental health center certified by the Ohio department of mental health. Services provided by an employee of the community mental health center must be billed directly to medicaid by the community mental health center. Costs incurred for physician ordered administration of aerosol therapy that is rendered by a licensed respiratory care professional are reimbursable through the facility cost report mechanism. No reimbursement for respiratory therapy services shall be made to a provider other than the intermediate care facility.

(F) Physician services

(1) A physician may be directly reimbursed for the following services provided to a resident of an intermediate care facility by a physician:

(a) All covered diagnostic and treatment services in accordance with Chapter 5101:3-4 of the Administrative Code.

(b) All medically necessary physician visits in accordance with rule 5101:3-4-06 of the Administrative Code.

(c) All required physician visits as described in this rule when the services are billed in accordance with rule 5101:3-4-06 of the Administrative Code.

(i) Physician visits must be provided to a resident of an intermediate care facility and are considered timely if they occur not later than ten days after the date the visit was required.

(ii) For reimbursement of the required physician visits, the physician must:

(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 (see) the patient except as provided in paragraph (F)(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 (F)(1)(c)(iv) of this rule and alternate between physician and visits by a physician assistant or certified nurse practitioner.

(iv) Physician delegation of tasks.

(a) A physician may delegate tasks to a physician assistant or certified nurse practitioner as defined by Chapter 4730. of the Revised Code and Chapter 4730-1 of the Administrative Code for physician assistants, and Chapter 4723. of the Revised Code and Chapter 4723-4 of the Administrative Code for certified nurse practitioners who are in compliance with the following criteria:

(i) Are acting within the scope of practice as defined by state law; and

(ii) Are under supervision and employment of the billing physician.

(b) A physician may not delegate a task when regulations specify that the physician must perform it personally, or when delegation is prohibited by state law or the facility's own policies.

(2) Services directly reimbursable to the physician must:

(a) Be based on medical necessity, as defined in rule 5101:3-1-01 of the Administrative Code, and requested by the resident of the intermediate care facility with the exception of the required visits defined in paragraph (F)(1)(c) of this rule; and

(b) Be documented by entries in the resident's medical records along with any symptoms and findings. Every entry must be signed and dated by the physician.

(3) Services provided in the capacity of overall medical direction are reimbursable only to an intermediate care facility and may not be directly reimbursed to a physician.

(G) Podiatry services

Covered services provided by licensed podiatrists are reimbursed directly to the authorized podiatric provider in accordance with Chapter 5101:3-7 of the Administrative Code. Payment is limited to one visit per month for residents in an intermediate care facility.

(H) Transportation services

Costs incurred by the intermediate care facility for transporting residents by means other than covered ambulance or ambulette services are reimbursable through the facility cost report mechanism. Payment is made directly to authorized providers for covered ambulance and ambulette services as set forth in Chapter 5101:3-15 of the Administrative Code.

(I) 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 5101:3-6 of the Administrative Code.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-12 Intermediate care facilities - medicaid cost report, record retention, and disclosure requirements.

(A) Each intermediate care facility shall file a medicaid cost report with the department.

The medicaid cost report, including its supplements and attachments as specified under paragraphs (B) to (M) of this rule must be submitted electronically within ninety days after the end of the reporting period. Except as specified under paragraph (F) of this rule, the medicaid cost report shall cover a calendar year or the portion of a calendar year during which the intermediate care facility participated in the medicaid program. In the case of an intermediate care facility that has a change of operator during a calendar year, the medicaid cost report by the new provider shall cover the portion of the calendar year following the change of operator encompassed by the first day of participation up to and including December thirty-first, except as specified under paragraph (H) of this rule. In the case of an intermediate care facility that begins participation after January first and ceases participation before December thirty-first of the same calendar year, the reporting period shall be the first day of participation to the last day of participation. The department shall make available the appropriate software for an electronically submitted medicaid cost report no later than sixty days prior to the initial due date of the medicaid cost report. For reporting purposes, intermediate care facilities shall use the chart of accounts as set forth in rule 5123:2-7-16 of the Administrative Code, or relate its chart of accounts directly to the medicaid cost report.

(B) For good cause, as deemed appropriate by the department, medicaid cost reports may be submitted within fourteen days after the original due date if written approval from the department is received prior to the original due date of the medicaid cost report. Requests for extensions must be in writing and explain the circumstances resulting in the need for an extension.

(1) For the purposes of this rule, "original due date" means each intermediate care facility's medicaid cost report is due ninety days after the end of each intermediate facility's reporting period. Unless waived by the department, the reporting period ends as follows:

(a) On the last day of the calendar year for the intermediate care facility's year-end medicaid cost report, except as provided in a paragraph (H)(2) of this rule; or

(b) On the last day of medicaid participation or when the intermediate care facility closes in accordance with rule 5123:2-7-02 of the Administrative Code; or

(c) On the last day before a change of operator; or

(d) On the last day of the new intermediate care facility's or new provider's first three full calendar months of participation under the medicaid program which encompasses the first day of medicaid participation.

(2) If an intermediate care facility does not submit the medicaid cost report within fourteen days after the original due date, or by the extension date granted by the department or submits an incomplete or inadequate report, the department shall provide written notice to the intermediate care facility that its provider agreement will be terminated in thirty days unless the intermediate care facility submits a complete and adequate medicaid cost report within thirty days of receiving the notice.

(3) During the thirty day termination period or any additional time allowed for an appeal of the proposed termination of a provider agreement, for each day a complete and adequate medicaid cost report is not received, the provider shall be assessed a late file penalty. The late file penalty shall be determined using the prorated medicaid days paid in the late file period multiplied by the penalty amount. The penalty amount shall be two dollars per patient day adjusted each July first for inflation during the preceding twelve months as stated in division (A)(2) of section 5111.26 of the Revised Code. The late file penalty period will begin the date the department issues its written notice and continue until the complete and adequate medicaid cost report is received by the department or the intermediate care facility is terminated from the medicaid program. The late file penalty shall be a reduction to the medicaid payment. No penalty shall be imposed during a fourteen-day extension granted by the department as specified in paragraph (B) of this rule.

(C) An addendum for disputed costs shall be an attachment to the medicaid cost report that an intermediate care facility may use to set forth costs the intermediate care facility believes may be disputed by the department. The costs stated on the addendum schedule are to have been applied to the other schedules or attachments as instructed by the medicaid cost report and/or chart of accounts for the cost report period in question (either in the reimbursable or the nonreimbursable cost centers). Any costs reported by the intermediate care facility on the addendum may be considered by the department in establishing the intermediate care facility's prospective rate.

(D) The department shall conduct a desk review of each medicaid cost report it receives.

Based on the desk review, the department shall make a preliminary determination of whether the reported costs are allowable costs. Before issuing the determination, the department shall notify the intermediate care facility of any information on the medicaid cost report that requires further support. The intermediate care facility 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 shall notify each intermediate care facility of any costs preliminarily determined not to be allowable and provide the reasons for the determination.

(1) The desk review is an analysis of the provider's medicaid 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 medicaid cost report without detailed verification and is designed to identify problems warranting additional review.

(2) An intermediate care facility may revise the medicaid cost report within sixty days after the original due date without the revised information being considered an amended medicaid cost report.

(3) The cost report is considered accepted after the medicaid cost report has passed the desk review process.

(4) After final rates have been issued, a provider who disagrees with a desk review decision may request a rate reconsideration.

(E) Except as provided in paragraph (E)(1) of this rule and not later than three years after a provider files a medicaid cost report with the department under section 5111.26 of the Revised Code, the provider may amend the medicaid cost report if the provider discovers a material error in the medicaid cost report or additional information to be included in the medicaid cost report. The department shall review the amended medicaid cost report for accuracy and notify the provider of its determination.

(1) A provider may not amend a medicaid cost report if the Ohio office of medical assistance has notified the provider that an audit of the medicaid cost report or a medicaid cost report of the provider for a subsequent medicaid cost reporting period is to be conducted under section 5111.27 of the Revised Code. The provider may, however, provide the Ohio office of medical assistance information that affects the costs included in the medicaid cost report. Such information may not be provided after the adjudication of the final settlement of the medicaid cost report.

(2) The department shall not charge interest under division (B) of section 5111.28 of the Revised Code based on any error or additional information that is not required to be reported under this paragraph. The department shall review the amended medicaid cost report for accuracy and notify the provider of its determination in accordance with section 5111.27 of the Revised Code.

(F) The annual medicaid cost report submitted by state-operated intermediate care facilities shall cover the twelve-month period ending June thirtieth of the preceding year, or portion thereof, if medicaid participation was less than twelve months.

(G) Medicaid cost reports submitted by county-operated and state-operated intermediate care facilities may be completed on accrual basis accounting and generally accepted accounting principles unless otherwise specified in Chapters 5101:3-3 or 5123:2-7 of the Administrative Code.

(H) Three-month medicaid cost reports:

(1) Facilities and providers new to the medicaid program shall submit a medicaid cost report pursuant to paragraph (B)(1) of this rule for the period which includes the date of certification and subsequent three full calendar months of operations. The new provider of an intermediate care facility that has a change of operator shall submit a medicaid cost report within ninety days after the end of the intermediate care facility's first three full calendar months after the change of operator.

(2) If an intermediate care facility described in paragraph (H)(1) of this rule opens or changes operators on or after October second, the intermediate care facility is not required to submit a year-end medicaid cost report for that calendar year.

(I) Providers are required to identify each known related party as defined in rule 5123:2-7-01 of the Administrative Code.

(J) Providers are required to identify all of the following:

(1) Each known individual, group of individuals, or organization not otherwise publicly disclosed who owns or has common ownership as defined in rule 5123:2-7-01 of the Administrative Code, in whole or in part, any mortgage, deed of trust, property or asset of the intermediate care facility. When the intermediate care facility or the common owner is a publicly owned and traded corporation, this information beyond basic identifying criteria is not required as part of the medicaid cost report but must be available within two weeks when requested. Publicly disclosed information must be available at the time of the audit; and

(2) Each corporate officer or director, if the provider is a corporation; and

(3) Each partner, if the provider is a partnership; and

(4) Each provider, whether participating in the medicare or medicaid program or not, which is part of an organization which is owned, or through any other device controlled, by the organization of which the provider is a part; and

(5) Any director, officer, manager, employee, individual, or organization having 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 of the Social Security Act, 42 U.S.C. 1395(2010) , Title XIX of the Social Security Act, 42 U.S.C 1396(2010) , or Title XX of the Social Security Act, 42 U.S.C. 1397(2010) ; and

(6) Any individual currently employed by or under contract with the provider, or related party organization, as defined under paragraph (I) of this rule, in a managerial, accounting, auditing, legal, or similar capacity who was employed by the department, the Ohio office of medical assistance, the Ohio department of health, the office of attorney general, the Ohio department of aging, the Ohio department of commerce, or the industrial commission of Ohio within the previous twelve months.

(K) Providers are required to provide upon request all contracts in effect during the medicaid cost report period for which the cost of the service from any individual or organization is ten thousand dollars or more in a twelve-month period; or for the services of a sole proprietor or partnership where there is no cost incurred and the imputed value of the service is ten thousand dollars or more in a twelve-month period, the audit provisions of 42 C.F.R. 420 subpart (D) (effective December 30, 1982), apply to these contractors.

(1) For the purposes of this rule, "contract for service" is defined as the component of a contract that details services provided exclusive of supplies and equipment. It includes any contract 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) For the purposes of this rule, "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 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.

(L) Financial, statistical, and medical records (which shall be available to the department, the Ohio office of medical assistance, and to the U.S. department of health and human services and other federal agencies) supporting the medicaid cost reports or claims for services rendered to residents shall be retained for the greater of seven years after the medicaid cost report is filed if the Ohio office of medical assistance issues an audit report, or six years after all appeal rights relating to the audit report are exhausted.

(1) Failure to retain the required financial, statistical, or medical records renders the provider liable for monetary damages 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.

(2) Failure to retain the required financial, statistical, or medical records to the extent that filed medicaid cost reports are unauditable shall result in the penalty as specified in paragraph (L)(1) of this rule. Providers whose records have been found to be unauditable will be allowed sixty days to provide the necessary documentation. If, at the end of the sixty days, the required records have been provided and are determined auditable, the proposed penalty will be withdrawn. If the Ohio office of medical assistance, after review of the documentation submitted during the sixty-day period, determines that the records are still unauditable, the department shall impose the penalty as specified in paragraph (L)(1) of this rule.

(3) Refusing access to financial, statistical, or medical records shall result in a penalty as specified in paragraph (L)(1) of this rule for outstanding medical services until such time as the requested information is made available to the department or the Ohio office of medical assistance.

(4) All requested financial, statistical, and medical records supporting the medicaid cost reports or claims for services rendered to residents shall be available at a location in the state of Ohio for intermediate care facilities certified for participation in the medicaid program by this state within at least sixty days after request by the state or its subcontractors. The preferred Ohio location is the intermediate care facility 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.

(M) When completing medicaid cost reports, the following guidelines shall be used to properly classify costs:

(1) All depreciable equipment valued at five hundred dollars or more per item and a useful life of at least two years or more, is to be reported in the capital cost component set forth under the Administrative Code. The costs of equipment acquired by an operating lease, including vehicles, 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 intermediate care facility's medicaid 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, shall continue to be reported under the capital cost component. The costs of any new leases for equipment executed on or after December 1, 1992, shall be reported under the capital costs component. Operating lease costs for equipment, which result from extended leases under the provision of a lease option negotiated on or after December 1, 1992, shall be reported under the capital cost component.

(2) Except for the employer's share of payroll taxes, workers' compensation, employee fringe benefits, and home office costs, allocation of commonly shared expenses across cost centers shall not be 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 intermediate care facility maintains adequate documentation of hours worked in each cost center. For example, the salary of an aide who is assigned to bathing and dressing chores in the early hours but works in the kitchen as a dietary aide for the remainder of the shift may be expended to separate cost centers provided the intermediate care facility maintains adequate documentation of hours worked in each cost center.

(3) The costs of resident transport vehicles are reported under the capital cost component. Maintenance and repairs of these vehicles is reported under the indirect care cost component.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-13 Intermediate care facilities - rate recalculations, interest on overpayments, penalties, repayment of overpayments, and deposit of repayment of overpayments.

(A) If a provider properly amends its medicaid cost report under rule 5123:2-7-12 of the Administrative Code, the Ohio office of medical assistance makes a finding based on an audit under section 5111.27 of the Revised Code, or the department makes a finding based on an exception review of resident assessment information conducted under section 5111.27 of the Revised Code after the effective date of the rate for direct care costs that is based on the assessment information any of which results in a determination that the provider has received a higher rate than it was entitled to receive, the department shall recalculate the provider's rate using the revised information. The department shall apply the recalculated rate to the periods when the provider received the incorrect rate to determine the amount of the overpayment. The provider shall refund the amount of the overpayment. In addition to requiring a refund under this rule, the department may charge the provider interest at the applicable rate specified in this rule from the time the overpayment was made.

(1) The interest shall be no greater than two times the average bank prime rate if the overpayment was equal to or less than one per cent of the total medicaid payments to the provider for the fiscal year for which the incorrect information was used to establish a rate.

(2) The interest shall be no greater than two and one-half times the average bank prime rate if the overpayment was greater than one per cent of the total medicaid payments to the provider for the fiscal year for which the incorrect information was used to establish a rate.

(3) The department shall determine the average bank prime rate using statistical release H.15, "Selected Interest Rates," a weekly publication of the federal reserve board (available at www.federalreserve.gov/releases/H15/), or any successor publication. If statistical release H.15, or its successor ceases to contain the bank prime rate information or ceases to be published, the department shall request a written statement of the average bank prime rate from the federal reserve bank of Cleveland or the federal reserve board.

(B) The department also may impose the following penalties and fines:

(1) If a provider does not furnish invoices or other documentation that the Ohio office of medical assistance requests during an audit within sixty days after the request, no more than the greater of one thousand dollars per audit or twenty-five per cent of the cumulative amount by which the costs for which documentation was not furnished increased the total medicaid payments to the provider during the fiscal year for which the costs were used to establish a rate.

(2) If an owner or operator fails to provide notice of facility closure, voluntary withdrawal or voluntary termination of participation in the medicaid program, or change of operator as required by the Revised Code, no more than the current average bank prime rate plus four per cent of the last two monthly payments.

(C) If the provider continues to participate in the medicaid program, the Ohio office of medical assistance shall deduct any amount that the provider is required to refund under this rule, and the amount of any interest charged or penalty imposed under this rule, from the next available payment from the department to the provider. The department and the provider may enter into an agreement under which the amount, together with interest, is deducted in installments from payments from the department to the provider.

(D) The Ohio office of medical assistance shall transmit all refunds and penalties issued under this rule to the treasurer of state for deposit in the general revenue fund.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-14 Intermediate care facilities - debt estimation, debt summary report, and successor liability agreements for change of operator, facility closure, voluntary termination, involuntary termination, or voluntary withdrawal.

(A) Debt estimation

(1) The Ohio office of medical assistance shall use the debt estimation methodology set forth in this rule to estimate the 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 office of medical assistance shall total the value of all of the following that are determined applicable in calculating the debt estimate:

(a) Overpayments determined due to the department pursuant to section 5111.27 of the Revised Code, including the following:

(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 the following:

(i) Penalties assessed pursuant to section 5111.28 of the Revised Code for lack of proper notice of a change of operator, facility closure, voluntary termination, or voluntary withdrawal from the medicaid program.

(ii) Late cost report filing penalties assessed pursuant to rule 5123:2-7-12 of the Administrative Code.

(iii) Penalties assessed pursuant to rule 5123:2-7-13 of the Administrative Code when a provider fails to furnish invoices or other documentation that the Ohio office of medical assistance requests during an audit.

(c) Interest monies owed to the department pursuant to section 5111.28 of the Revised Code, and to the centers for medicare and medicaid services pursuant to 42 C.F.R. 488.442(2011) .

(d) Monies owed to the department and the centers for medicare and medicaid services pursuant to sections 5111.68 and 5111.685 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.

(e) Franchise permit fee owed to the department pursuant to section 3721.53 or 5112.33 of the Revised Code which shall include unpaid franchise permit fee for the following:

(i) Amounts due for periods assessed or to be assessed but for which payment is not yet required pursuant to section 3721.53 or 5112.33 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 3721.54 or 5112.34 of the Revised Code for failure to pay the full amount when due.

(f) Monies owed for recapture of excess depreciation.

(g) Monies owed due to a credit balance.

(h) Monies owed pursuant to successor liability or assumption of liability agreements the exiting operator entered into.

(i) 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 (A)(2)(a) to (A)(2)(i) of this rule shall be the total estimated debt.

(4) The Ohio office of medical assistance may release a portion of funds withheld pursuant to division (A) of section 5111.681 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 5111.685 of the Revised Code.

(B) Provision of debt estimate

For the purposes of division (C) of section 5111.68 of the Revised Code, the debt estimate is considered provided by the Ohio office of medical assistance on the date of mailing or date of personal service.

(C) Initial debt summary report

(1) Whenever the Ohio office of medical assistance issues an initial debt summary report pursuant to section 5111.685 of the Revised Code, the Ohio office of medical assistance 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 days after the mailing of the initial debt summary report, the initial debt summary report becomes the final debt summary report thirty-one 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 office of medical assistance 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 office of medical assistance, 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 office of medical assistance 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 is sent by registered mail pursuant to this rule is returned because the affected party fails to claim the notice, the Ohio office of medical assistance 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) If any notice of an initial debt summary report is sent by registered or ordinary mail is returned for failure of delivery, the Ohio office of medical assistance shall make personal delivery of the notice by an employee or agent of the Ohio office of medical assistance. An employee or agent of the Ohio office of medical assistance 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 office of medical assistance of the refused mail as demonstrated by the Ohio office of medical assistance time and date 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 office of medical assistance 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 (C)(1) of this rule.

(b) The date that service is complete if notice is given pursuant to paragraph (C)(3) or (C)(5) of this rule.

(c) The date of personal service.

(7) If a request for review is mailed to the Ohio office of medical assistance office and address identified in the initial debt summary report, the request is deemed to have been made as follows:

(a) If the request is mailed by certified mail, as of the date stamped by the United States postal service on its receipt form.

(b) If the request 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 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 office of medical assistance office identified in the initial debt summary report as evidenced by that office's time stamp.

(8) If a request for review is made by facsimile transmission or 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 receipt date generated by the facsimile transmission or 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, made by facsimile transmission, 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 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 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.

(D) Revised debt summary report

(1) Whenever the Ohio office of medical assistance issues a revised debt summary report pursuant to section 5111.685 of the Revised Code, the Ohio office of medical assistance 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 days after the mailing of the revised debt summary report, the revised debt summary report becomes the final debt summary report thirty-one 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 office of medical assistance 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 office of medical assistance, 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 office of medical assistance 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 is sent by registered mail pursuant to this rule is returned because the affected party fails to claim the notice, the Ohio office of medical assistance 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) If any notice of a revised debt summary report sent by registered or ordinary mail is returned for failure of delivery, the Ohio office of medical assistance shall make personal delivery of the notice by an employee or agent of the Ohio office of medical assistance. An employee or agent of the Ohio office of medical assistance 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 office of medical assistance of the refused mail as demonstrated by the Ohio office of medical assistance time and date 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 office of medical assistance 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 (D)(1) of this rule.

(b) The date that service is complete if notice is given pursuant to paragraph (D)(3) or (D)(5) of this rule.

(c) The date of personal service.

(7) If a submission of additional information is mailed to the Ohio office of medical assistance office and address identified in the revised debt summary report, the request is deemed to have been made as follows:

(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 office of medical assistance office identified in the revised debt summary report as evidenced by that office's time stamp.

(8) If a submission of additional information is made by facsimile transmission or 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 receipt date generated by the facsimile transmission or 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, made by facsimile transmission, or made by electronic mail to a party or address other than the proper office identified in the revised debt summary report, the request 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 time stamp.

(10) If a submission of additional information is personally delivered to the office identified in the revised debt summary report, the request is deemed to have been made as of the date of its receipt as evidenced by that office's 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.

(E) Final debt summary report

Rule 5101:6-50-03 of the Administrative Code shall apply if a party timely submits a request for review, and additional information in response to a revised debt summary report, and the Ohio office of medical assistance issues a final debt summary report pursuant to section 5111.685 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.

(F) 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.

(G) Successor liability agreements

(1) Successor liability agreements entered into pursuant to section 5111.681 of the Revised Code are subject to approval by the Ohio office of medical assistance.

(2) Successor liability agreements must be signed by the exiting operator, the Ohio office of medical assistance, and the entity assuming liability pursuant to section 5111.681 of the Revised Code.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-15 Intermediate care facilities - payment and adjustment process.

(A) Forms

(1) Intermediate care facilities shall submit the Ohio office of medical assistance form 09400, "Nursing Facility Payment and Adjustment Authorization" (revised October 2012), directly to the Ohio office of medical assistance for the reimbursement of services.

(2) The county department of job and family services and intermediate care facilities shall use the Ohio office of medical assistance form 09401, "Facility/CDJFS Transmittal" (revised April 2011), to exchange information necessary to complete the billing process for payment.

(B) Notification of admission

The intermediate care facility shall notify the county department of job and family services by completing and forwarding form 09401 within five business days of admission of a new resident who is medicaid eligible or who has an application for medicaid that is pending.

(C) Notification of death

The intermediate care facility shall notify the county department of job and family services of the death of a medicaid resident by completing and forwarding form 09401 to the county department of job and family services within five business days following the death of the resident. The county department of job and family services shall terminate medicaid eligibility and stop vendor payment within ten days after the receipt of the form 09401.

(1) The county department of job and family services shall complete and return the form 09401, when appropriate, to the intermediate care facility within ten days of the receipt of the form 09401 for any required payment adjustment.

(2) The intermediate care facility shall complete the form 09400, when appropriate (e.g., final payment adjustment), within thirty days of the receipt of the form 09401 and submit it to the address indicated on form 09400.

(D) Notification of intermediate care facility discharge "Intermediate care facility discharge" has the same meaning as in rule 5123:2-7-08 of the Administrative Code. The intermediate care facility shall notify the county department of job and family services within five business days of the intermediate care facility discharge of a medicaid eligible resident by completing form 09401 identifying the type of intermediate care facility discharge, and forwarding form 09401 to the county department of job and family services. The county department of job and family services shall adjust medicaid eligibility within ten days after the receipt of form 09401. The county department of job and family services shall stop vendor payment within ten days after the receipt of form 09401.

(1) The county department of job and family services shall complete and return form 09401, when appropriate, to the intermediate care facility within ten days after the receipt of the form 09401 for any required payment adjustment.

(2) The intermediate care facility shall complete the form 09400, when appropriate (e.g., final payment adjustment), within thirty days of the receipt of the form 09401 and submit to the address indicated on form 09400.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-16 Intermediate care facilities - chart of accounts.

(A) Intermediate care facilities shall file medicaid cost reports with the department annually to comply with section 5111.26 of the Revised Code.

(1) The use of the chart of accounts in table 1 to table 8 of the appendix to this rule is recommended to establish the minimum level of detail to allow for medicaid cost report preparation.

(2) If the recommended chart of accounts is not used by the provider, it is the responsibility of the provider to relate its chart of accounts directly to the medicaid cost report.

(3) Where a chart of accounts number has sub-accounts, it is recommended that the sub-accounts capture the information requested so that the information will be broken out for medicaid cost reporting purposes.

(4) For example, when revenue accounts appear by payor type, it is required that those charges be reported by payor type where applicable; when salary accounts are differentiated between "supervisory" and "other," it is required that this level of detail be reported on the cost report where applicable.

(B) While the chart of accounts facilitates the level of detail necessary for medicaid cost reporting purposes, providers may find it desirable or necessary to maintain their records in a manner that allows for greater detail than is contained in the recommended chart of accounts.

(1) The recommended chart of accounts allows for a range of account numbers for a specified account.

(2) For example, account 1001 is listed for petty cash, with the next account, cash, beginning at account 1010. Therefore, a provider could delineate sub-accounts 1010-1, 1010-2, 1010-3, 1010-4, to 1010-9 as separate cash accounts. Providers need only use the sub-accounts applicable for their facility.

(C) Within the expense section (tables 5, 6, and 7), accounts identified as "salary" accounts are only to be used to report wages for facility employees.

(1) Wages are to include wages for sick pay, vacation pay, and other paid time off, as well as any other compensation to be paid to the employee.

(2) Expense accounts identified as "contract" accounts are only to be used for reporting the costs incurred for services performed by contracted personnel employed by the facility to do a service that would otherwise be performed by personnel on the facility's payroll.

(3) Expense accounts identified as "purchased nursing services" are only to be used for reporting the costs incurred for personnel acquired through a nursing pool agency.

(4) Expense accounts designated as "other" can be used for reporting any appropriate non-wage expenses, including contract services and supplies.

(D) Completion of the medicaid cost report as required in section 5111.26 of the Revised Code will require that the number of hours paid be reported (depending on facility type of control, on an accrual or cash basis) for all salary expense accounts. A provider's record keeping should include accumulating hours paid consistent with the salary accounts included within the recommended chart of accounts.

Click to view Appendix

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-17 Intermediate care facilities - leased staff services.

(A) "Leased staff services" means services provided by staff who are furnished to an intermediate care facility by a leasing firm under contract with the intermediate care facility.

(B) Costs related to leased staff services are reimbursable as other/contracted costs if all of the following apply:

(1) The intermediate care facility has contracted for leased staff services through an established staff leasing firm. An established staff leasing firm is one that is, and over a period of time has been, in the business of leasing staff in a variety of industries. Individuals with a variety of skills are generally included in the contractual agreement between the intermediate care facility and the staff leasing firm.

(2) The leased staff are present in the intermediate care facility on a consistent basis. It is the responsibility of the provider to maintain documentation showing continuity in staff.

(3) The contract between the intermediate care facility and the staff leasing firm is for a period of one year or more.

(4) The intermediate care facility maintains control over the day-to-day management of leased staff.

(C) Staff leasing arrangements are reimbursable through the medicaid cost reporting mechanism in the following manner:

(1) The wage component of fees paid to the staff leasing firm are reported in the direct care, indirect care, and other protected cost centers in other/contract wages (column 2) of the medicaid cost report for the applicable accounts as defined in rule 5123:2-7-16 of the Administrative Code.

(2) The payroll taxes and employee benefits portion of fees paid to the staff leasing firm are reported in the direct care, indirect care, and other protected cost centers in other/contract wages (column 2) of the medicaid cost report for the applicable accounts as defined in rule 5123:2-7-16 of the Administrative Code on the basis of dollars allocated to the appropriate employee benefit and payroll accounts.

(3) The payroll administration portion of fees paid to the staff leasing firm not identified as wages or benefits are reported in account 7305, administrative and general services, other indirect care (column 2) of the medicaid cost report as defined in rule 5123:2-7-16 of the Administrative Code. Payroll administration fees paid to a staff leasing firm meeting the definition of a related party as defined in rule 5123:2-7-01 of the Administrative Code are not reimbursable beyond those expenses that would be reimbursable if incurred by the provider itself.

(D) It is the provider's responsibility to maintain adequate documentation of the staff leasing costs.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.20 , 5111.226 , 5123.04
Rule Amplifies: 5111.20 , 5111.226 , 5123.04

5123:2-7-18 Intermediate care facilities - capital asset and depreciation guidelines.

(A) A per diem for depreciation on buildings, components, and equipment used in the provision of patient care that are not reimbursable by medicaid directly to the medical equipment supplier in accordance with rule 5101:3-3-19 of the Administrative Code is an allowable cost.

(B) For purposes of determining if an expenditure should be capitalized, the following guidelines are utilized:

(1) Any expenditure for an item that costs five hundred dollars or more and has a useful life of two or more years per item must be capitalized and depreciated over the asset's useful life.

(2) A provider may use a capitalization policy less than five hundred dollars per item, but is required to obtain prior approval from the department if the provider wishes to change its capitalization policy from its initial capitalization policy.

(C) All capital assets shall be depreciated using the straight-line method of depreciation.

(D) For purposes of determining the useful life of a capital asset, intermediate care facilities shall use the table as set forth in the appendix to this rule or a different useful life if approved by the department. If a capital asset is not reflected on the table as set forth in the appendix to this rule, the internal revenue service publication 946, "How to Depreciate Property" (revised 2011), available at http://www.irs.gov/publications/p946/index.html, shall be used for purposes of determining the useful life of that capital asset.

(E) The following depreciation conventions shall be used to calculate depreciation expense:

(1) 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.

(2) In the month that the 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 an asset be depreciated more than its adjusted basis.

(F) Providers shall maintain detailed depreciation schedules to verify each individual capital asset placed in service.

Click to view Appendix

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-19 Intermediate care facilities - nonreimbursable costs.

The following costs are not reimbursable to intermediate care facilities through the prospective reimbursement cost reporting mechanism, except as otherwise specified under Chapter 5123:2-7 of the Administrative Code. Nonreimbursable costs include, but are not limited to:

(A) Fines or penalties paid under sections 5111.28 , 5111.35 to 5111.62, 5111.683, and 5111.99 of the Revised Code.

(B) Disallowances made during the audit of the intermediate care facility's medicaid cost report which are sanctioned through adjudication in accordance with Chapter 119. of the Revised Code.

(C) Costs which exceed prudent buyer tests of reasonableness which may be applied pursuant to the provisions 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, during the audit of the intermediate care facility's medicaid cost report.

(D) The costs of ancillary services rendered to residents of intermediate care facilities by providers who bill medicaid directly. Ancillary services include, but are not limited to, physicians, legend drugs, radiology, laboratory, oxygen, and resident-specific medical equipment.

(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 office of medical assistance which are not upheld by the courts.

(I) Cost of meals sold to visitors or public (e.g., meals on wheels).

(J) Cost of supplies or services sold to persons who do not reside at the facility or the public.

(K) Cost of operating a gift shop.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.20 , 5111.226 , 5123.04
Rule Amplifies: 5111.20 , 5111.226 , 5123.04

5123:2-7-20 Intermediate care facilities - resident assessment classification and case mix payment system.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "Annual facility average case mix score" is the facility's average case mix score of all qualifying quarters in a calendar year.

(2) "Case mix payment system" is the system used to collect individual assessment form answer sheet data electronically submitted by providers for the purpose of assigning residents to the appropriate resident assessment classification group in accordance with paragraph (C) of this rule.

(3) "Case mix score" means the measure of the relative direct care resources needed to provide care and rehabilitation to a resident of an intermediate care facility.

(4) "Correction submission due date" is the deadline for the intermediate care facility to submit corrected individual assessment form answer sheets to the department. The correction submission due date applies to corrections submitted in electronic format for facility level and resident record changes.

(5) "Cost per case mix unit" is calculated by dividing the intermediate care facility's desk-reviewed, actual, allowable, per diem direct care costs for the calendar year preceding the fiscal year in which the rate will be paid by the annual facility average case mix score for the calendar year preceding the fiscal year in which the rate will be paid. The lesser of the intermediate care facility's cost per case mix unit or the maximum allowable cost per case mix unit for the intermediate care facility's peer group for the fiscal year shall be used to determine the intermediate care facility's rate for direct care costs, in accordance with sections 5124.19 to 5124.193 of the Revised Code.

(6) "Facility level errors" are errors which must be corrected before a facility average case mix score can be calculated and include the following:

(a) Failure to electronically submit the certification of individual assessment form data by the correction submission due date.

(b) Incomplete or inaccurate data are submitted to the department.

(c) The number of individual assessment form records processed is more than the reported number of residents in medicaid-certified beds on the reporting period end date.

(7) "Filing date" is the deadline for initial quarterly electronic submission of the intermediate care facility's individual assessment form data and the certification of individual assessment form data, which is the fifteenth calendar day following the reporting period end date.

(8) "Peer group" is a group of Ohio intermediate care facilities determined by the department to have significant per diem cost differences from other peer groups due to reasons other than the differences in care needs among the residents.

(9) "Processing quarter" is the quarter that follows the reporting quarter and is the quarter in which the department receives the individual assessment form data for the reporting quarter.

(10) "Quarterly facility average case mix score" is the facility average case mix score based on data submitted for one reporting quarter.

(11) "Record" means a resident's individual assessment form answer sheet processed by the department.

(12) "Relative resource weight" is 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.

(13) "Reporting period end date" is the last day of each calendar quarter.

(14) "Reporting quarter" is the quarter which precedes the processing quarter.

(15) "Resident assessment classification system" is the system for classifying residents of intermediate care facilities into case mix classifications used by the department to gather data for the direct care payment system. The case mix classifications are clusters of intermediate care facility residents, defined by resident characteristics, that explain resource use.

(16) "Resident case mix score" is the relative resource weight for the classification to which the resident is assigned based on data elements from the resident's individual assessment form.

(B) The department shall pay each eligible intermediate care facility a per resident per day rate for direct care costs established prospectively for each facility based on the intermediate care facility case mix payment system for direct care which includes the following components:

(1) The individual assessment form answer sheet which has been completed in accordance with the individual assessment form instructions;

(2) Individual assessment form data elements;

(3) A database which provides the core data elements that are used to group residents into case mix classifications;

(4) A method, set forth in paragraph (C) of this rule, that uses clinically meaningful criteria to group residents into one of six classifications;

(5) The identification of specific job types in the direct care cost category, set forth in paragraph (D) of this rule, that are affected by changes in case mix; and

(6) An assignment of a relative resource weight, as set forth in paragraph (E) of this rule, that measures the relative costliness of caring for residents in one group versus another.

(C) The intermediate care facility case mix payment system shall use the resident assessment classification system to classify residents of intermediate care facilities. Residents in each classification utilize similar quantities and patterns of resources. Based upon the data collected in the individual assessment form, a resident that meets the criteria for placement in more than one classification shall be placed in the highest classification according to the hierarchy. Residents without characteristics resulting in assignment to the higher classifications shall be placed in the sixth classification. The resident assessment classification system defines criteria used to assign residents to one of six mutually exclusive classifications listed in descending order of the hierarchy:

(1) The chronic medical classification includes residents receiving one or more of the following types of special care:

(a) Parenteral therapy on all shifts (on the individual assessment form at the medical domain section, item (24) is scored "4"),

(b) Tracheostomy care/suctioning on all shifts (on the individual assessment form at the medical domain section, item (25) is scored "4"),

(c) Oxygen and respiratory therapy on all shifts (on the individual assessment form at the medical domain section, item (27) is scored "4"),

(d) Oral medication administered more than eight times in a twenty-four-hour day (on the individual assessment form at the medical domain section, item (29a) is scored "3"),

(e) Topical medication administered more than eight times in a twenty-four-hour day (on the individual assessment form at the medical domain section, item (29b) is scored "3"),

(f) Injections of medication administered more than eight times in a twenty-four-hour day (on the individual assessment form at the medical domain section, item (29c) is scored "3"),

(g) Medication administered more than eight times in a twenty-four-hour day using a method other than oral, topical, or injection (on the individual assessment form at the medical domain section, item (29d) is scored "3"), and/or

(h) Utilization of out-of-home health care requiring over thirty days of staff time on average per year (on the individual assessment form at the medical domain section, item (31) is scored "3").

(2) The overriding behaviors classification includes residents exhibiting one or more of the following specific behaviors that require continual staff intervention as defined in the individual assessment form instructions:

(a) Aggressive behavior (on the individual assessment form at the behavior domain section, item (14) is scored "3"),

(b) Self-injurious behavior (on the individual assessment form at the behavior domain section, item (17) is scored "3"), and/or

(c) Acute suicidal behavior (on the individual assessment form at the behavior domain section, item (21) is scored "3").

(3) The high adaptive needs and chronic behaviors classification includes residents requiring a specific level of staff assistance/supervision for one or more personal care and safety needs described in paragraphs (C)(3)(a) to (C)(3)(f) of this rule and exhibiting one or more of the behaviors described in paragraphs (C)(3)(g) to (C)(3)(j) of this rule that require frequent or continual staff intervention as defined in the individual assessment form instructions:

(a) Eating (on the individual assessment form at the adaptive skills domain section, item (1) is scored "2" for needing hands-on assistance),

(b) Toileting (on the individual assessment form at the adaptive skills domain section, item (2) is scored either "3" for as a rule does not indicate the need to toilet and requires assistance with wiping, or "4" for requires colostomy, ileostomy, or urinary catheter),

(c) Dressing (on the individual assessment form at the adaptive skills domain section, item (5) is scored "3" for requiring hands-on assistance and/or constant supervision to complete the tasks, or tasks must be done completely by staff for the resident),

(d) Turning and positioning more than twelve times in a twenty-four-hour period (on the individual assessment form at the adaptive skills domain section, item (6) is scored "4"),

(e) Mobility requiring the help of one or more persons (on the individual assessment form at the adaptive skills domain section, item (7) is scored "3"),

(f) Transfer requiring direction and/or physical help from one or more persons (on the individual assessment form at the adaptive skills domain section, item (8) is scored "2"),

(g) Aggressive behavior requiring frequent staff intervention as defined in the instructions for completing the individual assessment form (on the individual assessment form at the behavior domain section, item (14) is scored "2"),

(h) Self-injurious behavior requiring frequent staff intervention as defined in the instructions for completing the individual assessment form (on the individual assessment form at the behavior domain section, item (17) is scored "2"),

(i) Disruptive behavior requiring continual staff intervention as defined in the individual assessment form (on the individual assessment form at the behavior domain section, item (19) is scored "4"), and/or

(j) Withdrawn behavior requiring continual staff intervention as defined in the instructions for completing the individual assessment form (on the individual assessment form at the behavior domain section, item (20) is scored "3").

(4) The high adaptive needs and non-significant behaviors classification includes residents requiring a specific level of staff assistance/supervision for one or more personal care and safety needs described in paragraphs (C)(3)(a) to (C)(3)(f) of this rule.

(5) The chronic behaviors and typical adaptive needs classification includes residents exhibiting one or more of the behaviors described in paragraphs (C)(3)(g) to (C)(3)(j) of this rule that require frequent or continual staff intervention as defined in the individual assessment form instructions.

(6) The typical adaptive needs and non-significant behaviors classification includes residents not meeting the criteria of the other five classifications.

(D) Analysis of staff time and resident assessment data, collected in a work measurement study of Ohio medicaid-certified intermediate care facilities 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 (D)(1) to (D)(8) of this rule are job types that perform activities that vary by case mix classification. 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 as described in paragraph (E) of this rule.

(1) Habilitation specialists consisting of nurse aides and habilitation staff;

(2) Licensed practical nurses;

(3) Occupational therapists;

(4) Program specialists;

(5) Qualified intellectual disability professionals;

(6) Registered nurses;

(7) Social workers/counselors; and

(8) Speech therapists.

(E) Each of the four resident classifications 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 paragraph (D) 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 by intermediate care facilities on the medicaid 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 fourth decimal place. Relative resource weights for the resident classifications are as follows:

(1) Chronic medical = 2.0888.

(2) Overriding behaviors = 1.9206.

(3) High adaptive needs and chronic behaviors = 1.8935.

(4) High adaptive needs and non-significant behaviors = 1.7434.

(5) Chronic behaviors and typical adaptive needs = 1.3593.

(6) Typical adaptive needs and non-significant behaviors = 1.000.

(F) Except as provided in paragraph (F)(1) 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 by intermediate care facilities on the medicaid cost report, and minutes of care per job type per resident assessment classification as follows:

(1) 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 medicaid cost report wage data from the most recent three calendar years available ninety days prior to the start of the fiscal year.

(2) The department may recalibrate relative resource weights more frequently if significant variances in wage ratios between job types occur.

(3) 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 intermediate care facility population.

(4) After recalibrating or rebasing relative resource weights under paragraph (F)(1), (F)(2), or (F)(3) 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.

(G) The department shall process individual assessment form data submitted by intermediate care facilities and classify residents using the resident assessment classification system to determine resident case mix scores. These resident case mix scores, based on relative resource weights as set forth in paragraph (E) of this rule, are used to establish the quarterly facility average case mix score. The methodology for determining the quarterly facility average case mix score is described in paragraph (L) of this rule.

(1) The individual assessment form shall be administered by intermediate care facility staff authorized by the department. In order to become authorized, intermediate care facility staff shall attend and successfully complete a training session conducted or approved by the department that includes a demonstration.

(2) Each intermediate care facility shall use the individual assessment form software provided by the department at no cost to complete and electronically submit to the department through the provider portal (https://doddportal.dodd.ohio.gov/PRV/IAFprov/Pages/default.aspx [File Link Not Available]) a quarterly case mix assessment for each resident of a medicaid-certified intermediate care facility bed, regardless of payment source or anticipated length of stay, to reflect the resident's condition on the reporting period end date, which is the last day of the calendar quarter. The electronic data shall be submitted in the exact layout provided in the individual assessment form software.

(3) The following residents shall be considered residents of a medicaid-certified bed on the reporting period end date:

(a) Residents admitted to the intermediate care facility prior to the reporting period end date and physically residing in the intermediate care facility on the reporting period end date; and

(b) Residents admitted to the intermediate care facility on the reporting period end date from another setting (e.g., home, hospital, adult care facility, or nursing facility); and

(c) Residents transferred or admitted into the intermediate care facility from another intermediate care facility on the reporting period end date; and

(d) Residents temporarily absent on the reporting period end date but for whom the facility 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.

(4) The following residents shall not be considered residents for a medicaid-certified bed as of the reporting period end date:

(a) Residents discharged from the intermediate care facility prior to or on the reporting period end date; and

(b) Residents transferred to another intermediate care facility prior to or on the reporting period end date; and

(c) Residents who die prior to or on the reporting period end date.

(5) Intermediate care facilities shall complete and electronically submit a certification of individual assessment form data with the quarterly submission of individual assessment form data identifying the name of the intermediate care facility, its provider number, the total number of beds the provider has certified by the Ohio department of health for medicaid, total number of residents in the intermediate care facility as of the reporting period end date for whom the provider must submit an individual assessment form, and the name of the authorized staff member who administered the assessment for each individual. The certification of individual assessment form data shall be electronically submitted to the department no later than the fifteenth day of the month following the reporting period end date.

(H) The annual facility average case mix score is used in conjunction with the lesser of the facility's cost per case mix unit or the maximum allowable cost per case mix unit, adjusted by the inflation rate, to establish the direct care rate, as outlined in sections 5124.19 to 5124.193 of the Revised Code. The facility's cost per case mix unit is calculated using the annual facility average case mix score. The methodology for determining the annual facility average case mix score is described in paragraph (M) of this rule.

(I) The department shall establish each intermediate care facility's rate for direct care costs annually in accordance with sections 5124.19 to 5124.193 of the Revised Code. The department shall assign a quarterly facility average case mix score or cost per case mix unit used to establish a facility's rate for direct care costs if the facility fails to submit its individual assessment form data in accordance with this rule or fails to correct facility level errors. Before taking such action, the department shall permit the provider a reasonable period of time to correct the information, as described in paragraph (K)(3) of this rule. The department's assignment of the quarterly facility average case mix score or cost per case mix unit will occur as follows:

(1) The department may assign a quarterly facility average case mix score that is five per cent less than the facility's quarterly average case mix score for the preceding calendar quarter instead of using the quarterly average case mix score calculated based on the facility's submitted information as described in paragraph (L) of this rule.

(a) If the facility was subject to an exception review conducted pursuant to rule 5123:2-7-30 of the Administrative Code for the preceding calendar quarter, the assigned quarterly facility average case mix score shall be the score that is five per cent less than the score determined by the exception review.

(b) If the facility was assigned a quarterly average case mix score for the preceding calendar quarter, the assigned quarterly facility average case mix score shall be the score that is five per cent less than that score assigned for the preceding quarter.

(2) The department may assign a cost per case mix unit that is five per cent less than the provider's calculated or assigned cost per case mix unit for the preceding calendar year if the provider has fewer than two acceptable quarterly average case mix scores.

(J) The department shall calculate and use the actual quarterly facility average case mix score described in paragraph (L) of this rule for determining the direct care rate if:

(1) The intermediate care facility submits individual assessment form data by the filing date and includes assessments for all residents of the intermediate care facility as of the reporting period end date; and

(2) In accordance with the procedures outlined in paragraph (K) of this rule for correcting inaccurate information, the intermediate care facility timely submits and timely corrects individual assessment form data for that reporting quarter; and

(3) The intermediate care facility's submission of individual assessment form data and the certification of individual assessment form data does not contain facility level errors or such errors have been timely corrected.

(K) After the department has processed the intermediate care facility's individual assessment form data for a reporting quarter, the department shall make available the "Case Mix Provider Summary Report" to the intermediate care facility. The intermediate care facility may correct errors or omissions identified by either the department or the intermediate care facility by sending in a modification submission and submitting corrections to the department along withan amended certification of individual assessment form data.

(1) The department shall notify intermediate care facilities of a missing or incomplete certification of individual assessment form data.

(2) The department may notify intermediate care facilities of its initial quarterly submission through two documents:

(a) The "Submission Tracking Summary" report which shows the status of the individual assessment form data after initial processing by the department.

(b) The "Detailed Listing of Successfully Grouped Assessments" report which is a list of individual assessment form records that were grouped into resident assessment classification system groups one through six.

(3) The department shall allow forty-five days after the reporting period end date for intermediate care facilities to make corrections and return them to the department. Timeliness of the submission to the department shall be determined by the electronic submission date.

(4) Corrections received by the department will be used in computing the quarterly facility average case mix score, in accordance with the conditions outlined in paragraph (J) of this rule.

(5) The department will process corrections submitted in electronic format if the file format is the same as used by the department.

(6) Changes made on the individual assessment form modification submission data element entries must be consistent with changes made to the original individual assessment form maintained at the facility.

(L) The quarterly facility average case mix score for intermediate care facilities that submitted individual assessment form data and modifications timely, and have no facility level errors is calculated as follows:

(1) All residents' case mix scores for the quarter are added together.

(2) The sum of resident case mix scores is divided by the total number of residents.

(M) The annual facility average case mix score is used to compute the cost per case mix unit for the intermediate care facility and the peer group maximum cost per case mix unit. Individual assessment form data for all four quarters of the calendar year shall be used to calculate the annual facility average case mix score:

(1) The department-assigned facility average case mix scores will be omitted from the facility's annual average case mix score calculation.

(2) The annual facility average case mix score shall be calculated from no fewer than two acceptable quarterly average case mix scores. Acceptable quarterly facility average case mix scores shall be summed and divided by the total number of quarters of acceptable scores. Acceptable quarterly average case mix scores for the purposes of calculating the annual facility average case mix score include, in order of hierarchy:

(a) Adjusted quarterly facility average case mix scores as a result of exception review findings, or

(b) Quarterly facility average case mix scores calculated based on the facility's submitted information as described in paragraph (L) of this rule.

(3) 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 (I)(2) of this rule.

Effective: 06/26/2014
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5124.02 , 5124.03 , 5124.19 , 5124.192 , 5124.193 , 5162.021 Rule Amplifies: 5123.04 , 5124.02 , 5124.03 , 5124.19 , 5124.191 , 5124.192 , 5124.193 , 5162.021
Prior Effective Dates: 01/10/2013, 10/01/2013

5123:2-7-21 Intermediate care facilities - compensation cost limits, reasonable costs for compensation, and compensation disallowances if any for owners and relatives of owners.

(A) Compensation cost limits for owners and relatives of owners shall be based upon compensation costs for individuals who hold comparable positions but who are not owners or relatives of owners, as reported on the intermediate care facility 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 owner's relative, if that position is listed separately on the intermediate care facility cost report, or if the position is not listed separately, the group of positions that is listed on the cost report and that includes the position held by the owner or the owner's relative. The compensation cost limits for owners and relatives of owners who function in positions listed on attachment 6 of the intermediate care facility 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 the following intermediate care facility cost reports excluding cost reports for providers of outlier services as specified in rule 5123:2-7-10 of the Administrative Code:

(a) Cost reports for intermediate care facilities with a December thirty-first end date; and

(b) Desk-reviewed and preliminarily determined to be allowable costs for intermediate care facilities.

(2) For each wage and hour chart of account number from attachment 6 of the intermediate care facility 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 under paragraph (A)(2)(a) of this rule by the total non-owner hours paid as calculated under paragraph (A)(2)(b) of this rule.

(d) Calculate the compensation cost limit by multiplying the average hourly rate as calculated under paragraph (A)(2)(c) of this rule by two thousand eighty hours.

(B) Compensation cost limits for an owner or an owner's relative who serves the intermediate care facility in a capacity such as corporate officer, for which no comparable position or group of positions is listed on attachment 6 shall be based upon the civil service equivalents. 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 facility and rendered in connection with patient care. The compensation cost limit for owners and relatives of owners who function in corporate positions shall be based upon the civil service equivalents as listed below and in the case of a proprietor or a partner, one of the below listed civil service equivalents shall be applied based upon the duties performed:

(1) Corporate president (a) Business administrator 3, class number 63317 for facilities with a combined bed total of one to ninety-nine; or

(b) Business administrator 4, class number 63318 for facilities with a combined bed total of one hundred to one hundred ninety-nine; or

(c) Fiscal officer 4, class number 66538 for facilities with a combined bed total of two hundred to two hundred ninety-nine; or

(d) Director 1, class number 61111 for facilities with a combined bed total of three hundred to five hundred ninety-nine; or

(e) Director 2, class number 61112 for facilities with a combined bed total of six hundred to one thousand one hundred ninety-nine; or

(f) Director 3, class number 61113 for facilities with a combined bed total of one thousand two hundred or more.

(2) Corporate vice-president (a) Program administrator 2, class number 63123 for facilities with a combined bed total of one to ninety-nine; or

(b) Program administrator 3, class number 63124 for facilities with a combined bed total of one hundred to one hundred ninety-nine; or

(c) Assistant director 1, class number 61211 for facilities with a combined bed total of two hundred to two hundred ninety-nine; or

(d) Assistant director 2, class number 61212 for facilities with a combined bed total of three hundred to five hundred ninety-nine; or

(e) Assistant director 3, class number 61213 for facilities with a combined bed total of six hundred to one thousand one hundred ninety-nine; or

(f) Assistant director 4, class number 61214 for facilities with a combined bed total of one thousand two hundred or more.

(3) Corporate treasurer (a) Fiscal specialist 1, class number 66531 for facilities with a combined bed total of one to ninety-nine; or

(b) Fiscal specialist 2, class number 66532 for facilities with a combined bed total of one hundred to one hundred ninety-nine; or

(c) Fiscal officer 1, class number 66535 for facilities with a combined bed total of two hundred to two hundred ninety-nine; or

(d) Fiscal officer 2, class number 66536 for facilities with a combined bed total of three hundred to five hundred ninety-nine; or

(e) Fiscal officer 3, class number 66537 for facilities with a combined bed total of six hundred to one thousand one hundred ninety-nine; or

(f) Fiscal officer 4, class number 66538 for facilities with a combined bed total of one thousand two hundred or more.

(4) Board secretary/member (a) Administrative professional 1, class number 16871 for facilities with a combined bed total of one to ninety-nine; or

(b) Office manager, class number 16821 for facilities with a combined bed total of one hundred to one hundred ninety-nine; or

(c) Administrative professional 4, class number 16874 for facilities with a combined bed total of two hundred to two hundred ninety-nine; or

(d) Program administrator 2, class number 63123 for facilities with a combined bed total of three hundred to five hundred ninety-nine; or

(e) Board/commission secretary 1, class number 62111 for facilities with a combined bed total of six hundred to one thousand one hundred ninety-nine; or

(f) Board/commission secretary 2, class number 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 intermediate care facility in the capacity of a corporate officer, proprietor, or partner as specified under paragraphs (B)(1) to (B)(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 under paragraphs (B)(1) to (B)(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 under paragraphs (B)(1) to (B)(4) of this rule will be based upon the owner's years of service in the health care field plus one.

(C) Reasonable costs for compensation and compensation disallowances for owners and relatives of owners are the facility's desk-reviewed, actual, allowable costs reported on schedule C-2 of the intermediate care facility cost report subject to the applicable compensation cost limits and audit by the Ohio office of medical assistance. For each owner or relative of an owner that has reported compensation on schedule C-2 of the intermediate care facility cost report shall perform the following steps.

(1) An owner and relative of an owner time slice is defined as follows:

(a) The number of days employed except when there is an overlap of an employment period for an owner or relative of an owner working in a related facility and the functions have the same position number; or

(b) When there is an overlap of an employment period for an owner or relative of an owner working in a related facility and the functions have the same position number, the number of days within an owner or relative of an owner compensation time slice for the individual is:

(i) The number of days employed for the overlap of an employment period when the individual is working in the related facility during the same period of time.

(ii) The number of days employed for the overlap of an employment period when the individual is working in the related facility during the same period of time.

(iii) The number of days employed subsequent to the overlapping employment period.

(2) For each owner and relative of an owner compensation time slice, calculate the following:

(a) Acquire the number of certified beds for the facility as of the end of the cost reporting period from schedule A, line 2, column 1 of the intermediate care facility cost report; and

(b) Acquire the number of certified beds from the intermediate care facility cost report for related facilities, as of the end of the cost reporting period; and

(c) Calculate the total number of certified beds by adding the number of certified beds for the facility as determined under paragraph (C)(2)(a) of this rule and the number of certified beds for any related facilities as determined under paragraph (C)(2)(b) of this rule.

(d) For owners and relatives of owners who received compensation as a corporate officer, acquire the appropriate corporate duty job step as calculated under paragraph (B)(5)(b) of this rule; and

(e) Determine the applicable compensation cost limit based on the position the owner or relative of an owner worked as follows:

(i) For owners and relatives of owners that are performing duties that are included on attachment 6 of the intermediate care facility cost report acquire the appropriate compensation cost limit as calculated under paragraph (A)(2)(d) of this rule subject to the following criteria:

(a) Compensation is allowable only for duties performed by owners which otherwise would require the employment of another individual.

(b) In order to qualify as a supervisor for positions listed on attachment 6 of the intermediate care facility cost report, the supervisor must supervise at least two individuals in facilities with fifty beds or more. In facilities with less than fifty beds, a supervisor may supervise one individual; or

(ii) For owners and relatives of owners who performed duties which otherwise would have required the employment of another individual and received compensation as a corporate officer, acquire the appropriate compensation cost limit as calculated under paragraph (B)(5) of this rule; and

(iii) For purposes of determining the compensation cost limits, owners and relatives of owners, are overtime exempt. There shall be no upward adjustment to the applicable compensation cost limit to accommodate circumstances where such individuals work in excess of forty hours per week.

(f) Calculate the number of days in the time slice for each individual by subtracting the beginning date from the ending date for each time slice and adding one; and

(g) Determine the total days in the calendar year; and

(h) Calculate the per cent of days allowed by dividing the number of days in the time slice as calculated under paragraph (C)(2)(f) of this rule by the total days in the calendar year as determined under paragraph (C)(2)(g) of this rule; and

(i) Calculate the time slice adjusted compensation cost limit by multiplying the per cent of days allowed as calculated under paragraph (C)(2)(h) of this rule by the adjusted compensation as calculated under paragraph (C)(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 intermediate care facility cost report; and

(k) Acquire the related weekly hours in the time slice for the appropriate time period from the related facilities' schedule C-2 of the intermediate care facility cost report; and

(l) Calculate the total weekly hours in the time slice by adding the weekly hours in the time slice as determined under paragraph (C)(2)(j) of this rule and the related weekly hours in the time slice as determined under paragraph(C)(2)(k) of this rule; and

(m) Calculate the maximum weekly hours:

(i) If the total weekly hours in the time slice as calculated under paragraph (C)(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 under paragraph (C)(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; and

(n) Calculate the hours allocation percentage by dividing the weekly hours in the time slice as calculated under paragraph (C)(2)(j) of this rule by the maximum weekly hours as calculated under paragraph (C)(2)(m) of this rule; and

(o) Calculate the final time slice adjusted compensation cost limit by multiplying the time slice adjusted compensation cost limit as calculated under paragraph (C)(2)(i) of this rule by the hours allocation percentage as calculated under paragraph (C)(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 intermediate care facility cost report. For each time slice, calculate the prorated owner and relative of an owner compensation amount 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 under paragraph (C)(2)(f) of this rule.

(q) Calculate the owner and relative of an owner compensation disallowance amount by subtracting the final time slice adjusted compensation cost limit as calculated under paragraph (C)(2)(o) of this rule from the prorated owner and relative of an owner compensation amount as calculated under paragraph (C)(2)(p) of this rule. The result cannot be less than zero.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-22 Intermediate care facilities - compensation cost limits, reasonable costs for compensation, and compensation disallowances if any for administrators.

(A) 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 intermediate care facility cost report from 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 the following intermediate care facility cost reports excluding cost reports for providers of outlier services as specified in rule 5123:2-7-10 of the Administrative Code:

(a) Cost reports for intermediate care facilities with a December thirty-first end date; and

(b) Desk-reviewed and preliminarily determined to be allowable costs for intermediate care facilities.

(2) For each administrator, calculate the hourly rate from schedule C-1 of the intermediate care facility 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; and

(b) Calculate the number of weeks worked by dividing the number of days employed by seven as calculated under paragraph (A)(2)(a) of this rule; and

(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 under paragraph (A)(2)(b) of this rule; and

(d) Calculate the hourly rate by dividing the weekly compensation amount as calculated under paragraph (A)(2)(c) of this rule by the weekly hours as reported on the cost report.

(3) Exclude any administrator's hourly rate as calculated under paragraph (A)(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 as determined in paragraph (A)(3) of this rule, calculate the average annual facility administrator salary for each facility from schedule C-1 of the intermediate care facility 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 under paragraph (A)(2)(a) of this rule; and

(b) For all administrators as reported for each facility total the following:

(i) Number of days employed as calculated under paragraph (A)(2)(a) of this rule; and

(ii) Compensation amounts as reported on the cost report; and

(iii) Hours worked as calculated under paragraph (A)(4)(a) of this rule; and

(c) Calculate a weighted facility average weekly hours by dividing the sum of the weighted weekly hours as calculated under paragraph (A)(4)(b)(iii) of this rule by the total number of days employed as calculated under paragraph (A)(4)(b)(i) of this rule; and

(d) Calculate the weighted facility compensation amount:

(i) If the weighted facility average weekly hours as calculated under paragraph (A)(4)(c) of this rule is less than thirty-five hours per week, multiply the total compensation amount as calculated under paragraph (A)(4)(b)(ii) of this rule by forty; or

(ii) If the weighted facility average weekly hours as calculated under paragraph (A)(4)(c) of this rule is thirty-five hours or more per week, multiply the total compensation amount as calculated under paragraph (A)(4)(b)(ii) of this rule by the weighted facility average weekly hours as calculated under paragraph (A)(4)(c) of this rule; and

(e) Calculate the total salary per year by dividing the weighted facility compensation amount as calculated under paragraph (A)(4)(d) of this rule by the weighted facility average weekly hours as calculated under paragraph (A)(4)(c) of this rule; and

(f) Calculate the average annual facility administrator salary by multiplying the total salary per year as calculated under paragraph (A)(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 under paragraph (A)(4)(b)(i) of this rule.

(5) Group the average annual facility administrator salary for each facility calculated in paragraph (A)(4)(f) of this rule into the following bed size categories based on certified bed size at the end of the cost reporting period:

(a) One to forty-nine; or

(b) Fifty to ninety-nine; or

(c) One hundred or more.

(6) For each bed size category under paragraph (A)(5) of this rule, calculate the compensation cost limit by summing the average annual facility administrator salary as calculated under paragraph (A)(4)(f) of this rule and dividing the total sum of all average annual facility administrator salary by the number of records summed.

(B) Reasonable costs for compensation and compensation disallowances for administrators are the facility's desk-reviewed, actual, allowable costs reported on schedule C-1 of the intermediate care facility cost report subject to the applicable compensation cost limits and audit by the Ohio office of medical assistance.

(1) For each individual administrator compensation reported on schedule C-1 of the intermediate care facility cost report perform the following steps:

(a) An individual administrator compensation time slice is defined as follows:

(i) The number of days employed except when there is an overlap of an employment period for an administrator working in a related facility; or

(ii) When there is an overlap of an employment period for an administrator working in a related facility, the number of days within an individual administrator compensation time slice for the administrator is:

(a) The number of days employed for the overlap of an employment period when the administrator is working in the related facility during the same period of time.

(b) The number of days employed preceding the overlapping employment period.

(c) The number of days employed subsequent to the overlapping employment period.

(b) For each administrator compensation time slice, calculate the following:

(i) Acquire the number of certified beds for the facility as of the end of the cost reporting period from schedule A, line 2, column 1 of the intermediate care facility cost report; and

(ii) Acquire the number of certified beds for related facilities that the administrator worked in, during the individual administrator compensation time slice, as of the end of the cost reporting period from schedule A, line 2, column 1 of the intermediate care facility cost report; and

(iii) Calculate the total number of certified beds by adding the number of certified beds for the facility as determined under paragraph (B)(1)(b)(i) of this rule and the number of certified beds for any related facilities that the administrator worked in determined under paragraph (B)(1)(b)(ii) of this rule; and

(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 under paragraph (B)(1)(b)(ii) of this rule to determine the appropriate compensation cost limit determined under paragraph (A)(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 under paragraph (A)(6) of this rule; and

(v) Acquire the allowance percentage from schedule C-1 of the intermediate care facility cost report which shall not exceed one hundred-fifty per cent; and

(vi) Calculate the adjusted compensation cost limit by multiplying the compensation cost limit determined under paragraph (B)(1)(b)(iv) of this rule by the allowance percentage determined under paragraph (B)(1)(b)(v) of this rule; and

(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; and

(viii) Determine the total days in the calendar year; and

(ix) Calculate the per cent of days allowed by dividing the number of days in the individual administrator compensation time slice as calculated under paragraph (B)(1)(b)(vii) of this rule by the total days in the calendar year as determined under paragraph (B)(1)(b)(viii) of this rule; and

(x) Calculate the time slice adjusted compensation cost limit by multiplying the per cent of days allowed as calculated under paragraph (B)(1)(b)(ix) of this rule by the adjusted compensation as calculated under paragraph (B)(1)(b)(vi) of this rule; and

(xi) Acquire the weekly hours in the individual administrator compensation time slice for the appropriate time period from schedule C-1 of the intermediate care facility cost report; and

(xii) Acquire the related weekly hours in the individual administrator compensation time slice for the appropriate time period from the related facilities' schedule C-1 of the intermediate care facility cost report; and

(xiii) Calculate the total weekly hours in the individual administrator compensation time slice by adding the weekly hours in the individual administrator compensation time slice as determined under paragraph (B)(1)(b)(xi) of this rule and the related weekly hours in the individual administrator compensation time slice as determined under paragraph (B)(1)(b)(xii) of this rule; and

(xiv) Calculate the maximum weekly hours:

(a) If the total weekly hours in the individual administrator compensation time slice as calculated under paragraph (B)(1)(b)(xiii) of this rule is less than thirty-five hours per week then the maximum weekly hours in the individual administrator compensation time slice is forty; or

(b)If the total weekly hours in the individual administrator compensation time slice as calculated under paragraph (B)(1)(b)(xiii) of this rule is greater than or equal to thirty-five hours per week then the maximum weekly hours in the individual administrator compensation time slice is the total weekly hours in the individual administrator compensation time slice; and

(xv) Calculate the hours allocation percentage by dividing weekly hours in the individual administrator compensation time slice as calculated under paragraph (B)(1)(b)(xi) of this rule by the maximum weekly hours as calculated under paragraph (B)(1)(b)(xiv) of this rule; and

(xvi) Calculate the final time slice adjusted compensation cost limit by multiplying the time slice adjusted compensation cost limit as calculated under paragraph (B)(1)(b)(x) of this rule by the hours allocation percentage as calculated under paragraph (B)(1)(b)(xv) of this rule; and

(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 intermediate care facility 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 under paragraph (B)(1)(b)(vii) of this rule; and

(xviii) Calculate the individual administrator compensation disallowance by subtracting the final time slice adjusted compensation cost limit as calculated under paragraph (B)(1)(b)(xvi) of this rule from the adjusted prorated administrator compensation amount as calculated under paragraph (B)(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 individual administrator compensation disallowance as calculated under paragraph (B)(1)(b)(xviii) of this rule from the adjusted prorated administrator compensation amount as calculated under paragraph (B)(1)(b)(xvii) of this rule.

(2) For each intermediate care facility, 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 facility as of the end of the cost reporting period from schedule A, line 2, column 1 of the intermediate care facility cost report; and

(b) Acquire the appropriate compensation cost limit for the bed size category using the total number of certified beds determined under paragraph (B)(2)(a) of this rule and the compensation cost limit determined under paragraph (A)(6) of this rule; and

(c) Establish the allowance percentage as one hundred-fifty per cent; and

(d) Calculate the adjusted compensation cost limit by multiplying the compensation cost limit determined under paragraph (B)(2)(b) of this rule by the allowance percentage determined under paragraph (B)(2)(c) of this rule; and

(e) Calculate the total administrator allowable compensation by summing the compensation reported on schedule C-1 of the intermediate care facility cost report for all administrators and subtracting any disallowances calculated under paragraph (B)(1)(b)(xviii) of this rule; and

(f) Calculate the overall facility administrator aggregate compensation disallowance by subtracting the adjusted compensation cost limit as calculated under paragraph (B)(2)(d) of this rule from the total administrator allowable compensation as calculated under paragraph (B)(2)(e) of this rule. The result cannot be less than zero.

(C) 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. Compensation for an administrator performing a direct care cost center function is allowable only for duties which otherwise would require the employment of another individual. The portion of the individual's total compensation paid by the intermediate care facility that may be reported in the direct care cost center shall be determined by multiplying the total compensation by the percentage of time the individual spends performing the direct care duties. The intermediate care facility must maintain records documenting the allocation of the individual's time to these 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 it is found that the intermediate care facility has not sufficiently documented the allocation of time, the cost associated with the undocumented time will be reclassified back to the indirect cost center. Those direct care cost center functions are:

(1) Medical director;

(2) Director of nursing;

(3) Activities director;

(4) Registered nurse;

(5) Licensed practical nurse;

(6) Recreational therapist;

(7) Psychologist;

(8) Respiratory therapist;

(9) Qualified intellectual disabilities professional;

(10) Licensed social worker/counselor;

(11) Chaplain;

(12) Charge nurse - registered nurse; and

(13) Charge nurse - licensed practical nurse.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-23 Intermediate care facilities - method for establishing the other protected costs component of the prospective rate.

(A) Each eligible intermediate care facility 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 for each facility. 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 under paragraph (B) of this rule and added to the per diem for the franchise permit fee as calculated under paragraph (C) of this rule to determine the total other protected cost component of the prospective rate.

(B) 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.

(C) Notwithstanding the methodology of reimbursement for other protected costs, as set forth under rule 5123:2-7-16 of the Administrative Code, the franchise permit fee rate in the amount equal to the assessment specified in section 5112.30 of the Revised Code will be included in the other protected cost center per diem rate for each intermediate care facility subject to the franchise permit fee assessment as specified in section 5112.31 of the Revised Code. The intermediate care facility 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 cost center under paragraph (B) of this rule.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-24 Intermediate care facilities - cost of ownership, efficiency incentive, and reporting of accumulated depreciation.

(A) For the purposes of this rule, the following definitions shall apply:

(1) "Cost of ownership" means the actual expense incurred for all of the following:

(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) Except as provided in table 7 of the appendix to rule 5123:2-7-16 of the Administrative Code, 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 medical assistance program, even if the project does not affect all medicaid-certified beds. Allowable extensive renovations are considered an integral part of cost 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" means the betterment, improvement, or restoration of an intermediate care facility 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 facility certified for participation in the medical assistance program, even if the project does not affect all medicaid-certified beds. A 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. A 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 a facility's licensed or certified capacity. Allowable nonextensive renovation projects are not considered cost of ownership.

(B) Cost of ownership

(1) The desk-reviewed, actual, allowable, per diem cost of ownership is based upon certified beds for property costs and equipment for the calendar year preceding the fiscal year in which the rate will be paid. The desk-reviewed, actual, allowable, per diem cost of ownership includes:

(a) The cost of ownership directly related to purchasing or acquiring capital assets including:

(i) Except as otherwise required by paragraph (F) of this rule, depreciation expense for the cost of building(s) equal to the actual cost depreciated under rule 5123:2-7-18 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.

(ii) Except as otherwise required by paragraph (F) of this rule, depreciation expense for major components of property and fixed equipment equal to the actual cost depreciated under rule 5123:2-7-18 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.

(iii) Except as otherwise required by paragraph (F) of this rule, depreciation expense for major movable equipment equal to the actual cost depreciated under rule 5123:2-7-18 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.

(iv) Interest expense incurred on money borrowed for construction or the purchase of real property, major components of that property, and equipment.

(v) 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.

(vi) Amortization expense of financing costs.

(b) The cost of ownership directly related to renting or leasing capital assets is the desk-reviewed, actual, allowable rent or lease expense of property and equipment.

(c) The cost of ownership directly related to the amortization of leasehold improvements. 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 under 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) Cost of ownership payments to intermediate care facilities shall not exceed the ceilings established in section 5111.251 of the Revised Code.

(3) For intermediate care facilities that have dates of licensure or that have 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, cost of ownership payments shall not exceed the ceilings established in section 5111.251 of the Revised Code, if the department gives prior approval for construction of the facility. The prior approval process for the purpose of increasing cost of ownership payments for new beds or relocated beds is as follows:

(a) Prior to commencement of construction, the provider must submit a request in writing to the department. This request should include:

(i) The projected completion date for the new intermediate care facility.

(ii) A projected budget for the new intermediate care facility 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 facility, the same information must be received for the existing facility and the facility to which the beds are to be relocated.

(b) The department shall review the proposal 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 will be evaluated across beds transferred to the new facility (or facilities) and the beds remaining in the existing facility.

(c) Approval for the increased cost of ownership payments will 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 cost of ownership payments, the lower cost of ownership ceiling will be effective.

(d) Written approval or denial of the preliminary request will be made by the department within sixty days of the date the initial request was made and the required documentation was received. Written documentation of the final determination will be provided by the department within sixty days from the date the new facility's actual three-month cost report is received.

(e) If the project continues to satisfy the cost neutrality standard, the higher cost of ownership ceiling will be implemented retroactively to the first day the new facility's medicaid provider agreement was effective. If the request is denied, the provider will continue to receive the lower cost of ownership ceiling.

(C) Intermediate care facilities which complete extensive renovations will receive a per diem for cost of ownership based upon the costs as specified under paragraph (B) of this rule.

(1) The date of licensure for an extensively renovated intermediate care facility shall be considered to be the date of completion of the extensive renovation.

(2) The current ceilings as calculated in accordance with section 5111.251 of the Revised Code shall be assigned to the extensively renovated facility using the date of licensure.

(3) An extensively renovated intermediate care facility which obtains new ceilings in accordance with this rule, shall not be permitted any reimbursement for nonextensive renovation under rule 5123:2-7-25 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 cost of ownership.

(4) An extensively renovated intermediate care facility shall not be permitted to receive any reimbursement for nonextensive renovation under rule 5123:2-7-25 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.

(D) The cost 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 as defined in rule 5123:2-7-01 of the Administrative Code shall 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.

(1) If a provider leases or transfers an interest in a facility to another provider who is a related party, the related party's allowable cost of ownership shall include the lesser of the following:

(a) The annual lease expense or actual cost of ownership, whichever is applicable; or

(b) The reasonable cost to the lessor or provider making the transfer.

(2) If a provider leases or transfers an interest in a facility to another provider who is a related party, regardless of the date of the lease or transfer, the related party's allowable cost of ownership shall include the annual lease expense or actual cost 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 (D)(2)(d)(i)(b) of this rule, in only the real property and any improvements on the real property;

(c) In the case of a transfer, the provider making the transfer retains, except as provided in paragraph (D)(2)(d)(ii)(b) of this rule, no ownership interest in the facility;

(d) The department determines that the lease or transfer is an arm's length transaction when the following apply:

(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 (D)(2)(b) of this rule, the facility itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a lessor.

(b) The lessor does not reacquire an interest in the facility except through the exercise of a lessor's rights in the event of a default. If the lessor reacquires an interest in the facility in this manner, the department shall treat the facility 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 facility or the facility itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a creditor. If the provider making the transfer maintains an interest as a creditor, the interest rate of the creditor shall not exceed the lessor of:

(i) The prime rate, as published by the "Wall Street Journal" on the first business day of the calendar year plus four per cent; or

(ii) Fifteen per cent.

(b) The provider that made the transfer does not reacquire an interest in the facility except through the exercise of a creditor's rights in the event of a default. If the provider reacquires an interest in the facility in this manner, the department shall treat the facility 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 facility, allowable cost of ownership was determined most recently.

(3) The provider proposing to lease or transfer an interest in a facility to a related party shall provide the department with a certified appraisal for each facility to be leased or transferred at least ninety days prior to the actual change of the provider agreement. The certified appraisal shall be conducted no earlier than one hundred eighty days prior to the actual change of the provider agreement for each facility leased or transferred to a related party.

(4) The provider proposing to lease or transfer an interest in a facility to a related party shall notify the department in writing and shall supply sufficient documentation demonstrating compliance with the provisions of this rule no less than ninety days before the anticipated date of completion of the transfer or lease. A provider that fails to supply the required documentation shall not qualify for a rate adjustment. The department shall issue a written decision determining whether the lease or transfer meets the requirements of this rule within sixty days after receiving complete information as determined by the department.

(E) Efficiency incentive The department shall pay each intermediate care facility an efficiency incentive that is equal to the amount calculated in accordance with section 5111.25 of the Revised Code.

(F) Reporting of accumulated depreciation

(1) Upon the sale of an intermediate care facility, the allowable capital asset cost basis, depreciation expense, and interest expense for the new provider/buyer of the intermediate care facility shall be the new provider's/buyer's actual depreciation and interest expense subject to the ceilings set forth previously under this rule. If the operating rights are separately identified and valued in a sale that includes both the building and the operating rights, the operating rights shall 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 intermediate care facility and uses the operating rights to create a new intermediate care facility or add beds to an existing intermediate care facility, the purchase price of the operating rights shall be added to the capital asset cost basis of the new intermediate care facility building or the additional beds.

(2) Upon the sale of an intermediate care facility, the initial accumulated depreciation for the new provider/buyer of the intermediate care facility shall be recalculated starting at zero.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-25 Intermediate care facilities - nonextensive renovation.

(A) For the purposes of this rule, "nonextensive renovation" means the betterment, improvement, or restoration of an intermediate care facility 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 facility certified for participation in the medical assistance program, even if the project does not affect all medicaid-certified beds. A 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. A 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 a facility's licensed or certified capacity. Allowable nonextensive renovations are not considered cost of ownership.

(B) Intermediate care facilities which complete nonextensive renovation shall receive the lesser of the ceiling determined under section 5111.251 of the Revised Code or an aggregate per diem based upon the costs as specified in this rule. 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 as defined in rule 5123:2-7-01 of the Administrative Code shall be based upon the lesser of the actual purchase of property and equipment costs or the actual costs of the related party. In order for costs to qualify for cost of nonextensive renovation, the following circumstances must be met.

(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 set forth under this rule which includes:

(i) Depreciation expense for the cost of buildings equal to the actual cost depreciated under rule 5123:2-7-18 of the Administrative Code for nonextensive renovations. 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 under 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 renovations under 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 following shall apply in order to determine if a project qualifies as a nonextensive renovation. For the purposes of this rule, "started" means the physical work has begun on the project at the site of the facility. Preliminary work such as planning, agency approval, feasibility surveys, and architectural drawings are not considered "started."

(a) The project results in the betterment, improvement, or restoration of an intermediate care facility beyond its current functional capacity through a structural change that costs at least five hundred dollars per bed; and

(b) When applying the five hundred dollars per bed requirement the following apply:

(i) If the project affects only the medicaid-certified part of a facility, all medicaid-certified beds in the facility will be considered when applying the minimum cost criteria; or

(ii) If the project affects the entire facility, all licensed beds will be considered when applying the minimum cost criteria; and

(c) The project does not increase the number of licensed beds; and

(d) If the facility 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 paragraph (B)(2) of this rule unless the project meets the requirements of extensive renovation as defined in rule 5123:2-7-24 of the Administrative Code; and

(e) The intermediate care facility has obtained prior approval under paragraph (B)(4) of this rule; and

(f) The intermediate care facility has satisfied all requirements for notice to the department upon completion of the project as set forth under paragraph (B)(6)(a) of this rule; and

(g) Unless the project is necessary to meet the requirements of federal, state, or local statutes, ordinances, rules, or polices, the department will not approve a project as a nonextensive renovation if fewer than five years have elapsed since the date of licensure of the portion of the intermediate care facility that is proposed to be renovated.

(3) To obtain prior approval from the department to report a project as a nonextensive renovation on the medicaid cost report, the following information must be submitted by the intermediate care facility prior to beginning construction of the proposed nonextensive renovation.

(a) A brief description of the project including the need for the project; and

(b) An estimate of the cost of the project, a list of work items summarizing the scope of the project, a copy of the estimate from the contractor that will undertake the project, and estimated total annual depreciation and interest expense for the project; and

(c) A sketch, diagram, or illustration of the facility prior to the project; and

(d) A sketch, diagram, or illustration of the facility showing the layout after completion of the project; and

(e) The estimated start and completion date of the project; and

(f) If the intermediate care facility is requesting an approval of a project under paragraph (B)(2)(g) of this rule, the applicable statute, ordinance, rule, or policy must be submitted along with an explanation of why the project is necessary to meet the requirements of federal, state, or local statutes, ordinances, rules, or policies; and

(g) The request must show the number of beds affected by each component of the project in order to determine the minimum cost requirement set forth under paragraph (B)(2)(b) of this rule.

(4) When reviewing a request for prior approval to report a project as a nonextensive renovation, the department shall:

(a) Request in writing any additional information needed to review the request for prior approval; and

(b) Determine whether the project meets the definition of a nonextensive renovation; and

(c) Determine whether the project satisfies all the requirements of a nonextensive renovation as set forth under paragraph (B)(2) of this rule; and

(d) Determine whether the estimated costs of the project are allowable; and

(e) Notify the provider in writing that the request for prior approval to report a project as a nonextensive renovation has been granted or denied. After prior approval is granted, the provider shall comply with the following:

(i) The nonextensive renovation project must be started within six months after the date the department grants approval; and

(ii) The nonextensive renovation project must 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 cost per bed requirement under paragraph (B)(2)(a) of this rule. Failure to satisfy the conditions under this paragraph shall result in costs of the project being reported as cost of ownership in lieu of nonextensive renovation in accordance with paragraph (B)(6)(c) of this rule.

(f) Written approval from the department of a project as a nonextensive renovation shall clearly state that the approval of any additional costs as set forth under paragraph (B)(5) of this rule must be approved in writing by the department in order to qualify as nonextensive renovation.

(5) Additional notice to the department is required during the course of the construction of the approved nonextensive renovation if any of the following circumstances occur:

(a) The completion of the nonextensive renovation project is delayed or accelerated by more than four months from the estimated date of completion.

(b) The actual cost of construction exceeds the approved cost by the greater of ten per cent or two thousand dollars.

(i) Upon receiving notice of the cost increase, 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 (B)(4) of this rule; or

(ii) If the department does not approve the additional costs, expenses related to all costs in excess of the approved amount will be reported as cost of ownership; or

(iii) If the provider fails to provide notice to the department of the increased costs, expenses related to all costs in excess of the approved amount will be reported as cost of ownership.

(c) The actual amount financed exceeds the approved amount financed by the greater of ten per cent or two thousand dollars.

(i) 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 (B)(4) of this rule; or

(ii) If the department does not approve the additional amount financed, interest expense related to all amounts financed in excess of the approved amount will be reported as cost of ownership; or

(iii) If the provider fails to provide notice to the department of the increased amount financed, interest expense related to all amounts financed in excess of the approved amount will be reported as cost of ownership.

(d) The actual interest rate exceeds the projected interest rate by two percentage points or more.

(i) Upon receiving notice of the increased interest rate, the department may approve the interest expense associated with the increased interest rate for inclusion as nonextensive renovations. In reviewing a project for approval under this paragraph, the department shall apply the criteria specified in paragraph (B)(4) of this rule; or

(ii) If the department does not approve the increased interest rate, the interest expense associated with the incremental increase in the approved interest rate will be reported as cost of ownership; or

(iii) If the provider fails to provide notice to department of the increased interest rate, the interest expense associated with the incremental increase in the approved interest rate will be reported as cost of ownership.

(e) Any increase or decrease in the scope of the nonextensive renovation project.

(i) 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; or

(ii) If the department does not approve the project as revised, the additional costs associated with the increase in scope shall be reported as cost of ownership; or

(iii) 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 increase in scope shall be reported as cost of ownership.

(f) Any change of cost that 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.

(6) An approved nonextensive renovation project shall be reported as follows:

(a) Before a nonextensive renovation or portion thereof can be reported on a medicaid cost report, notice of completion must be submitted to the department. The notice of completion must include:

(i) The date the project or portion thereof was placed in service; and

(ii) 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 under paragraph (B)(3)(b) of this rule; and

(iii) A detailed reconciliation of actual financing costs to the projected financing cost in the request for approval of a nonextensive renovation.

(b) A nonextensive renovation may be reported on the medicaid 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 under paragraph (B)(4)(e) of this rule and in the aggregate satisfy the five hundred dollar bed requirement under paragraph (B)(2)(a) of this rule.

(c) If the total cost of all the portions of the entire project that have been placed into service within the period set forth under paragraph (B)(4)(e) of this rule do not satisfy the cost per bed requirement under paragraph (B)(2)(a) 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 in cost of ownership.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-26 Intermediate care facilities - active treatment day programming.

(A) The costs of active treatment day programming shall be part of the direct care costs of an intermediate care facility as off-site active treatment day programming.

(B) An active treatment program, that is developed in accordance with 42 C.F.R. 483.440(1991) , identifies active treatment programming services that are provided to a resident. Active treatment day programming services must be delivered off-site of the residence unless the interdisciplinary team sets forth in the resident's individual plan the reasons why delivering active treatment day programming services off-site would be contra-indicated for the resident. The determination must be supported by the evaluations and assessments contained in the individual program plan and by the condition and/or behavior of the resident.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-27 Intermediate care facilities - prospective rate reconsideration on the basis of possible calculation errors.

(A) An intermediate care facility, group, or association may request a reconsideration of a prospective intermediate care facility rate on the basis of a possible error in the calculation of the rate as follows:

(1) A request for reconsideration of a prospective rate on the basis of a possible error in the calculation of the rate shall be filed with the department no more than thirty days after the later of the initial payment of the rate or the receipt of the rate setting calculation.

(2) The request for a reconsideration of a prospective rate on the basis of a possible error in the calculation of the rate shall be filed in accordance with the following procedures:

(a) 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" or faxed to (614) 466-0652; and

(b) The request shall indicate that it is a request for rate reconsideration due to a possible error in the calculation of the rate; and

(c) The request shall include a detailed explanation of the possible error and the proposed corrected calculation; and

(d) The request shall include references to the relevant sections of the Revised Code and/or paragraphs of the Administrative Code as appropriate.

(3) The department shall respond in writing within sixty days of receiving a written request for reconsideration of a prospective rate due to a possible error in the calculation of the rate. If the department requests additional information to determine whether a rate adjustment is warranted, the intermediate care facility shall respond in writing and shall provide additional supporting documentation no more than thirty days after the receipt of the request for additional information. The department shall respond in writing within sixty days of receiving the additional information to the request for reconsideration of a prospective rate due to a possible error in the calculation of the rate.

(4) If a rate adjustment is warranted as the result of a reconsideration of a prospective rate due to a possible error in calculation, the adjustment shall be implemented retroactively to the initial service date for which the rate is effective.

(B) 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.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-28 Intermediate care facilities - prospective rate reconsideration on the basis of extreme hardship upon admission of a resident from a state-operated developmental center.

(A) An intermediate care facility may request a reconsideration of a rate on the basis of an extreme hardship on the facility only as follows:

(1) Upon direct admission of a resident from a state-operated developmental center to the intermediate care facility, a request for reconsideration of a prospective rate on the basis of extreme hardship on the facility may be filed with the department no more than ninety days after admission of the former resident to the intermediate care facility.

(a) 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" or faxed to (614) 466-0652; and

(b) The request shall indicate that it is a request for rate reconsideration due to the admission to the intermediate care facility of a former resident of a state-operated developmental center; and

(c) The request shall include a detailed summary of the facts supporting the request, including demonstration of the increased costs and the requested adjusted facility per diem rate.

(2) The department shall respond in writing within sixty days of receiving a written request for reconsideration of a prospective rate due to extreme hardship on the facility. If the department requests additional information to determine whether a rate adjustment is warranted, the intermediate care facility shall respond in writing and shall provide additional supporting documentation within thirty days of receipt of the request for additional information. The department shall respond in writing within sixty days of receiving the additional information to the request for reconsideration of a prospective rate.

(3) If a rate adjustment is granted by the department, the adjustment shall be implemented the first day of the first month the former developmental center resident resides in the intermediate care facility. 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 resident permanently leave the intermediate care facility for any reason.

(4) The maximum amount available for each admitted former resident of a state-operated developmental center shall be no more than fifty dollars per day, with the rate determined by the following formula:

(a) Divide fifty dollars by the number of filled beds in the intermediate care facility including the bed occupied by the individual from the state-operated developmental center. This will be added to the facility's per diem rate until the end of the state fiscal year.

(b) If the twelve consecutive months cross a state fiscal year, the calculation in paragraph (A)(4)(a) 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.

(5) If a rate adjustment is granted to a facility that subsequently undergoes a change of ownership, the adjusted rate shall remain in place as though a change of ownership had not occurred.

(B) The department has sole discretion in the determination of whether an extreme hardship exists; 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.

Effective: 01/10/2013
R.C. 119.032 review dates: 01/10/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.226 , 5123.04
Rule Amplifies: 5111.02 , 5111.226 , 5123.04

5123:2-7-29 Intermediate care facilities - outlier services for pediatric ventilator services.

(A) Purpose

The purpose of this rule is to identify a subpopulation of persons determined to require an intermediate care facility level of care whose care needs are not adequately measured by the individual assessment form or by the resident assessment classification and case mix payment system described in rule 5123:2-7-20 of the Administrative Code.

(B) For the purposes of this rule, the following definitions shall apply:

(1) "Designated outlier coordinator" means a designated department staff member who coordinates the general operations of the intermediate care facility outlier program. The designated outlier coordinator works with providers of outlier services, individuals and other persons whom individuals have identified requesting and receiving outlier services, 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 intermediate care facilities providing outlier services;

(b) Coordinating the processing of pre-admission and continued stay prior authorization requests for individuals; and

(c) Reviewing assessments, individual plans, day programming plans, staffing plans, and other documents.

(2) "Individual plan" means a written description of the services to be provided to an individual, developed by an interdisciplinary team that represents the professions, disciplines, or service areas that are relevant to identifying the individual's needs, as described by the comprehensive functional assessments.

(3) "Intermediate care facility for pediatric ventilator services" means a facility that holds an effective intermediate care facility provider agreement with the Ohio department of medicaid and that is approved by the department to deliver outlier services to individuals under twenty-two years of age who are dependent on invasive mechanical ventilators.

(4) "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.

(5) "Level of care review" means the evaluation of an individual's physical, mental, and social/emotional status to determine the level of care required to meet the individual's service needs and includes activities necessary to safeguard against unnecessary utilization. Level of care determinations are based upon the criteria regarding the amount and type of services needed by an individual that are set forth in Chapter 5101:3-3 of the Administrative Code.

(6) "Outlier services" means those clusters of services that have been determined by the department to require reimbursement rates established pursuant to section 5124.152 of the Revised Code when delivered by qualified providers to individuals who have been prior-authorized for the receipt of a category of service identified as an outlier service by the department as set forth in Chapter 5123:2-7 of the Administrative Code.

(7) "Physician" means a doctor of medicine or osteopathy who is licensed to practice medicine.

(8) "Plan of correction" means a corrective action plan prepared by an intermediate care facility in response to deficiencies cited by the department or the Ohio department of health. The plan shall conform to regulations and guidelines, and shall include 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 facility will ensure that compliance will be maintained upon correction.

(9) "Prior authorization assessment for intermediate care facility pediatric ventilator services" means an evaluation to determine if an individual meets the criteria to be served by an intermediate care facility for pediatric ventilator services as outlined in paragraphs (C)(3) to (C)(7) of this rule, and shall 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.

(10) "Prior authorization for intermediate care facility pediatric ventilator services" means department approval obtained by an intermediate care facility for pediatric ventilator services on behalf of a specific individual for specific time-limited initial or continued stay periods at the intermediate care facility for pediatric ventilator services. Prior authorization for intermediate care facility pediatric ventilator services shall be required for the provider to be authorized by the department to receive reimbursement for services rendered to the individual. Reimbursement may be denied for any service not rendered in accordance with Chapters 5101:3-3 and 5123:2-7 of the Administrative Code.

(a) Initial prior authorization for intermediate care facility pediatric ventilator services.

Unless the individual is seeking a change of payer, the prior authorization for intermediate care facility pediatric ventilator services shall occur prior to admission to the intermediate care facility for pediatric ventilator services.

(b) Continued stay prior authorization for intermediate care facility pediatric ventilator services.

In the case of requests for continued stay, the prior authorization for intermediate care facility pediatric ventilator services shall occur no later than the final day of the previously authorized intermediate care facility for pediatric ventilator services stay.

(C) Individual eligibility criteria

To receive prior authorization for intermediate care facility pediatric ventilator services, an individual shall meet all the following criteria:

(1) Financial eligibility

The individual shall have been determined by the county department of job and family services to meet the medicaid financial eligibility standards for institutional care.

(2) Level of care determination

The individual shall have obtained a level of care determination from the department within the last thirty days, or, at the time of prior authorization assessment for intermediate care facility pediatric ventilator services, be determined by the department to meet the criteria for a level of care as set forth in rule 5101:3-3-07 of the Administrative Code.

(3) Age

The individual shall be under twenty-two years of age.

(4) Need for services

The individual shall have a complex medical condition requiring the use of an invasive mechanical ventilator.

(5) Currently receiving services

The individual shall meet one of the following criteria:

(a) The individual shall have been 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 and has needs, specifically including invasive mechanical ventilation, that cannot be met by services available in a non-institutional setting; or

(b) The individual resides at an intermediate care facility on the effective date of this rule and has needs, specifically including invasive mechanical ventilation, that cannot be met by services available in a non-institutional setting.

(6) Physician services

The individual's medical condition must have stabilized so that the immediate services of an acute care hospital, including daily physician visits, are not medically necessary.

(7) Nursing services

The individual shall require monitoring by a nurse twenty-four hours per day and professional assessment by a registered nurse on a daily basis.

(D) Provider eligibility criteria

Prior to enrollment as an intermediate care facility for pediatric ventilator services, and at regular intervals thereafter, the department shall determine whether the intermediate care facility for pediatric ventilator services provider qualifications are fulfilled through review of documentation of appropriate policies and procedures, on-site visits, and other mechanisms. In order to be approved as an intermediate care facility for pediatric ventilator services and qualify for enhanced payment for provision of intermediate care facility pediatric ventilator services to prior-authorized individuals, a provider shall meet all of the following criteria:

(1) Certified intermediate care facility and consent to oversight

The provider shall be an Ohio medicaid certified intermediate care facility and shall agree to cooperate with the department's oversight of intermediate care facility pediatric ventilator services.

(2) Intermediate care facility provider agreement

The provider shall meet the requirements set forth in rule 5123:2-7-02 of the Administrative Code in order to obtain a provider agreement.

(3) Licensure survey findings

Prior to approval by the department as a provider of intermediate care facility pediatric ventilator services, the provider shall:

(a) Be in full compliance with residential facility licensure standards; or

(b) Have an approved and implemented plan of correction and have not demonstrated a pattern of repeat deficiencies.

(4) Certification survey findings

Prior to approval by the department as a provider of intermediate care facility pediatric ventilator services, the provider shall:

(a) Fully meet all standards for medicaid intermediate care facility certification; or

(b) 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.

(5) Emergency needs

(a) The intermediate care facility shall have an emergency action plan in place in the event of a power failure.

(b) The intermediate care facility shall have on-site backup generator service for all equipment including suction lines, oxygen lines, and emergency power to ventilators.

(c) The intermediate care facility shall have 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.

(d) The intermediate care facility shall have 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.

(6) Facility staffing

(a) Availability of direct care staff.

Providers shall schedule direct care staff to ensure that adequately trained staff are present and on duty seven days per week, twenty-four hours per day, every day of the year. Staffing shall 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 the resident's individual plan. Absences of staff for breaks and meals shall not compromise this requirement.

(b) Management experience.

Staff who manage intermediate care facility pediatric ventilator services shall have evidence of at least two years of work experience with individuals who have complex medical conditions.

(c) Staff training.

Staff training programs shall address 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 intermediate care facility pediatric ventilator services. Initial and continuing direct care staff training shall include all of the following:

(i) Orientation to the facility's status as a provider of intermediate care facility pediatric ventilator services, including the individual eligibility criteria outlined in paragraph (C) of this rule and the provider eligibility criteria outlined in paragraph (D) of this rule;

(ii) Information about the disorders and diseases affecting the current residents of the intermediate care facility pediatric ventilator services provider;

(iii) Accepted best practices and innovative approaches to meet residents' needs;

(iv) Training to ensure nursing care competence for patients under twenty-two years of age, 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 intermediate care facilities for pediatric ventilator services, staff training shall include steps to be taken to minimize risk of transmission of contagious or infectious diseases.

(7) Service delivery

The provider shall 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 intermediate care facility cost report mechanism or directly to the provider of such services.

(a) The facility shall ensure that physician services are available twenty-four hours per day.

(b) A physician shall complete an assessment of the individual at least once every thirty days for the first ninety days and at least once every ninety 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 intermediate care facility for pediatric ventilator services, a physician shall complete an assessment of the individual at least once every thirty days for the first ninety days and at least once every ninety days thereafter.

(c) The facility shall ensure that licensed respiratory care practitioner services are available twenty-four hours per day. Medically necessary respiratory care services shall be provided by a licensed respiratory care practitioner and/or by a nurse, who the facility has determined has the training, knowledge, skill, and ability to complete the services in coordination with the licensed respiratory care practitioner, and as ordered by a physician.

(d) The facility, in consultation with a physician and a licensed respiratory care practitioner, shall develop a facility plan for providing care to individuals who are dependent on invasive mechanical ventilators. The plan shall address maintenance of ventilators, required modification and maintenance of facilities, and 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.

(e) The facility shall ensure that registered nursing services are available twenty-four hours per day.

(f) Nursing care and any personal care that may be required for the health, safety, and wellbeing of the individuals served shall be available twenty-four hours per day. Nursing personnel shall 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.

(g) The need for physical, occupational, and/or speech therapy services shall be assessed and services shall be provided as needed.

(h) If an individual is receiving enteral feedings and there is a complication of medical status secondary to the nutritional status, a dietary consultation shall be made available to that individual.

(8) Service collaboration and day programming

Prior to an individual's admission to an intermediate care facility for pediatric ventilator services, the provider shall arrange for a suitable school or day program for the individual and shall submit the plan for such program to the designated outlier coordinator or other department designee.

(9) Preliminary evaluation

(a) Prior to an individual's admission to an intermediate care facility for pediatric ventilator services, the provider shall 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.

(b) Health information shall include a copy of the medical assessment completed by a pediatric physician who has knowledge of and experience with the individual and shall include 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.

(10) Ongoing monitoring

A registered nurse shall submit a written summary of clinical status to the primary care physician on a monthly basis. The physician shall review and sign the summary and place it in the individual's medical record.

(11) Transitional plan

Due to the complex and intensive needs of individuals being admitted to an intermediate care facility for pediatric ventilator services, the provider shall develop a transitional plan prior to admission of an individual to ensure that the facility is able to meet the individual's health, safety, and behavioral needs from the day of admission. The transitional plan shall address major concerns and shall be provided to the designated outlier coordinator or other department designee upon request.

(12) Initial assessment

Within thirty days after admission, the provider shall 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)(9) of this rule, which was conducted prior to admission. The provider shall provide the assessments or reassessments to the designated outlier coordinator or other department designee upon request.

(13) Individual plan, significant change in medical status, and quarterly report

(a) Within thirty days of an individual's admission, the facility, with input from the individual, the individual's parent, the individual's guardian, or other person whom the individual has identified, as applicable, shall develop a comprehensive individual plan. The individual plan shall 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. The facility shall provide a copy of the individual plan to the designated outlier coordinator or other department designee upon request.

(b) The facility shall notify the designated outlier coordinator or other department designee whenever an individual experiences a significant change in medical status, including hospitalization.

(c) The facility shall prepare a quarterly report in a format approved by the department that summarizes the resident's individual 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 facility shall provide a copy of the quarterly report to the designated outlier coordinator or other department designee upon request.

(d) The designated outlier coordinator or other department designee may visit the facility at any time. The facility shall provide any documents or information requested by the designated outlier coordinator or other department designee.

(14) Discharge plan

Within thirty days after admission, the facility shall develop a written discharge plan developed by the interdisciplinary team in conjunction with the individual and others concerned with the individual's welfare. The discharge plan shall include a description of targeted medical/health status indicators that would signify the resident could be safely discharged. The facility shall provide a copy of the discharge plan to the designated outlier coordinator or other department designee upon request

(15) Continued stay denials

If prior authorization is denied during an assessment that was requested for an individual already residing in the intermediate care facility for pediatric ventilator services, the intermediate care facility shall accept payment for the provision of services at the non-outlier intermediate care facility reimbursement rate.

(16) Outlier per diem rate add-on

(a) A facility per diem rate shall be set in accordance with Chapter 5124. of the Revised Code and applicable rules in Chapter 5123:2-7 of the Administrative Code. An outlier per diem rate add-on for pediatric ventilator services, determined and applied in accordance with paragraph (H) of this rule, shall be added to the facility per diem rate.

(b) With the exception of any specific items that are direct-billed in accordance with rule 5123:2-7-11 of the Administrative Code, the provider shall agree to accept as payment in full the per diem rate established for intermediate care facility pediatric 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 intermediate care facility pediatric ventilator services.

(E) Prior authorization for services

Payment for intermediate care facility pediatric ventilator services covered by the medicaid program shall 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 level of care review process set forth in rule 5123:2-7-06 of the Administrative Code.

(1) Submission of requests

(a) All requests for prior authorization for intermediate care facility pediatric ventilator services 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" or faxed to (614) 466-0652.

(b) Requests shall be sent to the designated outlier coordinator or other department designee.

(c) A request is considered submitted when it is received by the designated outlier coordinator or other department designee.

(2) Initial request requirements

It is the responsibility of the provider to ensure that all required information is provided to the department as requested. An initial request for prior authorization for intermediate care facility pediatric ventilator services is considered complete when all of the following requirements have been met:

(a) The Ohio department of job and family services form 03142, "Prior Authorization" (revised March 2008), has been appropriately completed and submitted;

(b) The Ohio department of job and family services form 03697, "Level of Care Assessment" (revised April 2003), or an alternative form specified by the department that accurately reflects the individual's current mental and physical condition and is certified by a physician has been appropriately completed and submitted;

(c) In accordance with the level of care review process for intermediate care facilities set forth in rule 5123:2-7-06 of the Administrative Code, a level of care determination has been issued in accordance with rule 5101:3-3-07 of the Administrative Code and a determination regarding the feasibility of community-based care has been made; and

(d) The intermediate care facility for pediatric ventilator services has submitted to the designated outlier coordinator the prior authorization request form and supporting documentation exhibiting evidence that the applicant meets criteria listed in paragraphs (C)(3) to (C)(7) of this rule. The provider shall retain a duplicate copy of all submitted documentation. 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.

(3) Initial stay assessment

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 intermediate care facility pediatric 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.

(4) Prior authorization determination

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 shall 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 intermediate care facility pediatric ventilator services.

(5) Notice of determination

When a request for prior authorization for intermediate care facility pediatric ventilator services has been processed by the department, the department shall issue a notice of determination indicating approval or denial of the request by mail or fax to the individual, the individual's parent, the individual's guardian, or other person whom the individual has identified, as applicable, and the provider.

(a) Denial

When a request for prior authorization for intermediate care facility pediatric ventilator services is denied, the department shall issue a notice of denial and the individual's right to a state hearing in accordance with Chapter 5101:6-2 of the Administrative Code. The notice shall include an explanation of the reason for the denial. The department shall send a copy of the notice to the county department of job and family services to be filed in the individual's case record.

(b) Approval

When a request for prior authorization for intermediate care facility pediatric ventilator services is approved, the department shall issue an approval letter that includes an assigned prior authorization number, the number of days for which intermediate care facility pediatric ventilator services are authorized, and the date on which payment is authorized to begin. The approval letter shall include the name, location, and phone number of the department staff member who is assigned to monitor the individual's progress in the facility. The department shall send a copy of the approval letter to the county department of job and family services to be filed in the individual's case record.

(i) Authorization for initial stay

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 up to a maximum of six months, or up to one hundred eighty-four days. The number of months or days that is prior-authorized for each eligible individual shall 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 length of stay in the intermediate care facility for pediatric ventilator services.

(ii) Authorization for continued stays

Continued stay determinations shall be based on reports from the facility 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 provider submits a request for continued stay in accordance with paragraph (E)(6)(b) of this rule, continued stays may be approved for maximum increments of six months, up to one hundred eighty-four days.

(c) Reimbursement for services provided by an intermediate care facility for pediatric ventilator services shall be limited to services approved as indicated in the approval letter.

(6) Discharge

(a) 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 shall be monitored by the department or its designee throughout the individual's stay in the intermediate care facility for pediatric ventilator services.

(b) Intermediate care facility pediatric ventilator services may be extended beyond the previously approved length of stay if the provider submits a written request to the department proving that it is not possible to implement the individual's discharge plan. Such requests shall be submitted at least thirty 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.

(F) Application for designation as a provider of intermediate care facility for pediatric ventilator services

The facility shall complete and submit to the department an application for designation as a provider of intermediate care facility for pediatric ventilator services (available at http://dodd.ohio.gov/medicaid/Documents/Application%20for%20Pediatric%20Ventilator%20Services%20Program.pdf ). The facility shall provide any additional information requested by the department and may be subject to on-site visits by department personnel.

(G) Payment authorization

The payment authorization date shall be one of the following, but shall not be earlier than the effective date of the individual's level of care determination:

(1) The date of admission to the intermediate care facility for pediatric ventilator services if it is within thirty days of the physician's signature on the Ohio department of job and family services form 03697, "Level of Care Assessment" (revised April 2003), or an alternative form specified by the department; or

(2) The date of intermediate care facility for pediatric ventilator services prior authorization approval, if the individual was already a resident of an intermediate care facility for pediatric ventilator services but was using another payer source; or

(3) A date other than that specified in paragraph (G)(1) or (G)(2) of this rule. This alternative date may be authorized only upon receipt of a letter by the designated outlier coordinator or other department designee that contains a credible explanation for the delay from the originator of the request for prior authorization of intermediate care facility pediatric ventilator services. If the request is to backdate the level of care and intermediate care facility for pediatric ventilator services eligibility determination more than thirty days from the physician's signature, the physician shall verify the continuing accuracy of the information and need for inpatient care either by adding a statement to that effect on the form 03697 or an alternative form specified by the department, or by attaching a separate letter of explanation.

(H) Initial and subsequent contracted rates

The department shall 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 shall be effective the first day of the first month following the admission or discharge of an individual meeting the requirements set forth in this rule, including prior authorization requirements set forth in paragraph (E) of this rule.

(1) An intermediate care facility for pediatric ventilator services serving one individual meeting the requirements set forth in paragraph (C) of this rule and prior-authorized for intermediate care facility pediatric ventilator services shall be eligible for the outlier per diem rate add-on using the following formula:

Divide three hundred dollars by the number of licensed beds in the intermediate care facility including the bed occupied by the individual receiving intermediate care facility pediatric ventilator services. The result will be added to the facility's per diem rate.

(2) An intermediate care facility for pediatric ventilator services serving more than one individual meeting the requirements set forth in paragraph (C) of this rule and prior-authorized for intermediate care facility pediatric ventilator services shall be eligible for the outlier per diem rate add-on using the following formula:

Multiply the number of individuals residing in the intermediate care facility prior-authorized to receive intermediate care facility pediatric ventilator services by three hundred dollars. Divide the product by the number of licensed beds in the intermediate care facility including the beds occupied by the individuals receiving intermediate care facility pediatric ventilator services. The result will be added to the facility's per diem rate.

(3) The amount of the intermediate care facility pediatric ventilator services outlier per diem rate add-on shall be recalculated when individuals eligible for intermediate care facility pediatric ventilator services are admitted or discharged, when individuals become ineligible, as well as during each rate-setting process for the intermediate care facility. The provider shall be responsible for contacting the designated outlier coordinator no later than by the close of the next business day following the discharge of an individual to ensure processing time for recalculation and application of the outlier per diem rate add-on to the facility per diem rate.

(4) If the department obtains the ability to utilize person-specific rates, the outlier per diem rate add-on will be specific to the individual approved to receive pediatric ventilator services in the amount of three hundred dollars.

Effective: 10/01/2013
R.C. 119.032 review dates: 10/01/2018
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5124.02 , 5124.03 , 5124.152 , 5162.021
Rule Amplifies: 5123.04 , 5124.02 , 5124.03 , 5124.15 , 5124.152 , 5124.25 , 5162.021

5123:2-7-30 Intermediate care facilities - exception review process.

(A) Purpose

The purpose of this rule is to set forth the process by which the department shall conduct exception reviews.

(B) Definitions

(1) "Exception review" means a review conducted of selected intermediate care facilities by appropriate health professionals employed by or under contract with the department for purposes of identifying inaccuracies related to the individual assessment form data submitted in accordance with rule 5123:2-7-20 of the Administrative Code, which result in inaccurate case mix scores being used to calculate an intermediate care facility's direct care rate. Exception reviews shall be conducted before the annual rates are established pursuant to section 5124.15 of the Revised Code. Exception reviews shall be conducted in accordance with applicable provisions of the medicaid program.

(2) "Exception review tolerance level" means an acceptable level of variance in the calculation of the quarterly facility average case mix score of the intermediate care facility. The variance is calculated as a percentage of the difference between the score based on exception review findings compared to the score based on the individual assessment form data submitted by the intermediate care facility for that quarter. The exception review tolerance level is a two per cent difference between the quarterly facility average case mix score based on exception review findings and the quarterly facility average case mix score based on individual assessment form data submitted by the intermediate care facility.

(3) "Resident assessment classification system" means the system for classifying residents of intermediate care facilities into case mix classifications used by the department to gather data for the direct care payment system. The case mix classifications are clusters of intermediate care facility residents, defined by resident characteristics, that explain resource use.

(C) Selection process

(1) The department shall select intermediate care facilities for exception review based on:

(a) The findings of a certification survey conducted by the Ohio department of health that may indicate that the intermediate care facility is not accurately assessing residents which may result in inaccurate classification of the residents in the resident assessment and classification system;

(b) A risk analysis of an intermediate care facility with a noticeable change in the frequency distribution of the residents in the resident assessment classification system classifications not attributable to a change in resident population or a significant change in the intermediate care facility's average case mix score not attributable to a change in resident population or an intermediate care facility for which other data indicate that the individual assessment form data submitted by the intermediate care facility may not result in accurate classification of the intermediate care facility's residents in the resident assessment classification system; or

(c) Prior resident assessment performance of the intermediate care facility, including, but not limited to, ongoing problems with assessment submission deadlines, error rates, incorrect assessment dates, and apparent unchanged assessment practices following the department's review performed pursuant to section 11 of House Bill 303 of the 129th General Assembly or a subsequent exception review.

(2) The department may contact an intermediate care facility during the selection process for clarification of information. The intermediate care facility may be able to satisfactorily resolve the department's concerns and avert an on-site review.

(D) Requirements for persons conducting exception reviews

Exception reviews shall be conducted at the intermediate care facility by qualified intellectual disability professionals, registered nurses, and other licensed or certified health professionals employed by or under contract with the department. When a team of department reviewers conducts an on-site exception review, the team shall be led by a qualified intellectual disability professional. Persons conducting exception reviews shall meet the following conditions:

(1) During the period of their employment or contract with the department, reviewers must neither have nor be committed to acquire any direct or indirect financial interest in the ownership, financing, or operation of an intermediate care facility which they review in Ohio. Employment of a member of a reviewer's family by an intermediate care facility that the reviewer does not review does not constitute a direct or indirect financial interest in the ownership, financing, or operation of an intermediate care facility.

(2) Reviewers shall not review any intermediate care facility that has been a client or employer of the reviewer during the previous twelve months.

(3) Reviewers shall not review any intermediate care facility where a member of the reviewer's family is a current resident.

(E) Prior notice

The department shall notify the intermediate care facility by telephone at least two working days prior to the exception review. At the discretion of the department, the review team may reschedule the exception review if appropriate key personnel of the intermediate care facility are unavailable on the originally scheduled date of the on-site portion of the exception review.

(F) Access to persons and information

Intermediate care facilities selected for exception reviews shall provide department reviewers with reasonable access to residents, professional and unlicensed direct care staff, the intermediate care facility assessors, and residents' completed individual assessment forms, as well as other documentation regarding residents' care needs and treatment. Intermediate care facilities shall also provide the department with sufficient information to be able to contact residents' attending or consulting physicians, other professionals from all disciplines who have observed, evaluated, or treated residents such as contracted therapists, and residents' family/significant others. These sources of information may help to validate information provided on the individual assessment form data submitted to the department. Verification activities may include reviewing residents' individual assessment forms and supporting documentation, conducting interviews with staff knowledgeable about the resident, and observing or interviewing the resident.

(G) Exception review sample

An exception review shall be conducted of a pre-selected random, targeted, or combination sample of completed individual assessment forms from the reporting quarter. If the results of the pre-selected sample indicate inaccuracies which require a larger sample, the department may expand the sample.

(H) Exit conference

At the conclusion of the on-site portion of the exception review process, department reviewers shall hold an exit conference with intermediate care facility representatives. Reviewers shall share preliminary findings and/or concerns about verification or failure to verify resident assessment classification system classifications for reviewed records. At the time of the exit conference, the intermediate care facility shall be afforded an opportunity to present additional information or items which depict the needs of residents for whom the intermediate care facility contests the sample findings.

(I) Written summary of exception review findings

All exception reviews shall include a written summary of exception review findings. The department shall send a copy of the written summary of findings to the intermediate care facility.

(J) Records retention

All exception review reports shall be retained by the department for at least six years from the date the exception review report is final.

(K) Calculation or recalculation of resident case mix scores

If the exception review tolerance level is exceeded, the department shall use the exception review findings to calculate or recalculate resident case mix scores, quarterly facility average case mix scores, and annual facility average case mix scores. Calculations or recalculations shall apply only to records actually reviewed by the department and shall not be based on extrapolations of findings to unreviewed records. Rates calculated based on exception review findings may result in an increase or decrease compared to the rate based on the intermediate care facility's assessment of information.

(L) Reconsideration

(1) An intermediate care facility may submit a written request for reconsideration to the department not later than thirty days after it receives the written summary of exception review findings pursuant to paragraph (I) of this rule. The request shall include:

(a) A detailed explanation of the items in the assessment results that the intermediate care facility disputes;

(b) Copies of relevant supporting documentation from specific resident records; and

(c) The intermediate care facility's proposed resolution of the disputes.

(2) The department shall consider all of the information submitted by the intermediate care facility, the historic results of the assessments, and any other information determined necessary for consideration.

(3) The department shall issue a written decision regarding reconsideration within thirty days of receiving the request.

(4) The department's decision is final and not subject to further appeal.

(5) When calculating intermediate care facility case mix scores, the department shall use any resident case mix scores adjusted as a result of a rate consideration determination.

Effective: 10/01/2013
R.C. 119.032 review dates: 10/01/2018
Promulgated Under: 119.03
Statutory Authority: 5123.04 , 5124.02 , 5124.03 , 5124.193 , 5162.021
Rule Amplifies: 5123.04 , 5124.02 , 5124.03 , 5124.193 , 5162.021