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