Chapter 5160-2 | Hospital Services

Rule 5160-2-01 | Eligible providers.

• Effective: August 20, 2023
• Promulgated Under: 119.03

(A) All hospitals, except those excluded in paragraphs (A)(1) and (A)(2) of this rule, that meet medicare (Title XVIII) conditions of participation as described in 42 C.F.R 482 effective as of October 1, 2022, are eligible to participate in the Ohio medicaid (Title XIX) program upon execution of a provider agreement. Also considered to be eligible is a hospital that is currently determined to meet the established criteria for Title XVIII participation and has in effect a hospital utilization review plan applicable to all patients who receive medical assistance under Title XIX. The following hospitals are excluded from participation:

(1) Tuberculosis hospitals, and

(2) Hospitals that have fifty per cent or more of their beds registered pursuant to Chapter 3701-59 of the Administrative Code as alcohol and/or drug abuse rehabilitation beds, and have no beds licensed as psychiatric beds pursuant to Chapter 5122-14 of the Administrative Code.

(B) Freestanding psychiatric hospitals with more than sixteen beds may provide inpatient psychiatric services in accordance with paragraphs (B)(1) to (B)(4) of this rule:

(1) For individuals aged sixty-five or older, hospitals will operate pursuant to the provisions of 42 C.F.R. 441 subpart C effective as of October 1, 2022.

(2) For individuals under age twenty-one, hospitals will operate pursuant to the provisions of 42 C.F.R. 441 subpart D effective as of October 1, 2022.

(3) For individuals aged twenty-one or older, but under age sixty-five, hospitals will operate pursuant to the provisions of 42 C.F.R. 482 subpart E effective as of October 1, 2022.

(4) In the case of an individual under age twenty-two, the hospital will provide services before the individual reaches age twenty-one or, if the individual was receiving services immediately before they reached age twenty-one, then before the earlier of the following:

(a) The date the individual no longer needs the services; or

(b) The date the individual reaches age twenty-two.

(C) Ohio medicaid will not reimburse freestanding psychiatric hospitals with more than sixteen beds for inpatient psychiatric services rendered to individuals aged twenty-one or older, but under age sixty-five, except in accordance with the provisions of 42 C.F.R. 438.6(e) effective as of October 1, 2022.

(D) Freestanding psychiatric hospitals with sixteen or fewer beds may provide inpatient psychiatric services to individuals of any age and will operate pursuant to the provisions of 42 C.F.R. 482 subpart E effective as of October 1, 2022.

Last updated August 21, 2023 at 8:45 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 8/20/2028
Prior Effective Dates: 12/21/1977, 6/1/1985, 11/10/1991

Rule 5160-2-02 | General provisions: hospital services.

• Effective: July 12, 2024
• Promulgated Under: 119.03

For purposes of Chapter 5160-2 of the Administrative Code, the following definitions apply, unless the context clearly indicates otherwise:

(A) "Diagnosis related groups (DRGs)" is a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources in an inpatient setting. The groupings used to assign cases to a DRG for claim payment and the grouping logic used to develop relative weights for DRG's are described in rule 5160-2-65 of the Administrative Code.

(B) "Discharged" means a patient who:

(1) Is formally released from a hospital;

(2) Dies while hospitalized;

(3) Is discharged within the same hospital from an acute care bed and admitted to a bed in an inpatient psychiatric facility, or is discharged within the same hospital from a bed in an inpatient psychiatric facility to an acute care bed. Rule 5160-2-65 of the Administrative Code explains the payment methodology for these types of discharges; or

(4) Signs himself or herself out against medical advice.

(C) "Enhanced Ambulatory Patient Groups (EAPGs)" is a group of outpatient procedures, encounters, or ancillary services, that reflect similar patient characteristics and resource utilization and incorporate the use of "International Classification of Diseases" diagnosis codes, current procedural terminology (CPT) code set, and healthcare common procedure coding system (HCPCS) procedure codes.

(D) "Hospital" has the same meaning as in rule 5160-2-01 of the Administrative Code.

(E) "Inpatient" is a patient who is admitted to a hospital based upon the written orders of a practitioner of physician services as described in paragraph (L) of this rule and whose inpatient stay continues beyond midnight of the day of admission.

(F) "Inpatient psychiatric facility" or "distinct part psychiatric unit" means a hospital or unit of a hospital that focuses on the treatment of the behavioral health needs of a patient and is excluded from the medicare inpatient prospective payment system in accordance with 42 C.F.R. 412.25 effective as of October 1, 2022.

(G) "Inpatient services" means services that are ordinarily furnished in a hospital for the care and treatment of patients. Inpatient services include all covered services provided to patients during their inpatient stay, whether furnished directly by the hospital or under arrangement, except for direct-care services provided by a practitioner of physician services as defined in paragraph (L) of this rule. Emergency room services are covered as an inpatient service when a patient is admitted from the emergency room.

Outpatient services provided within three calendar days prior to the date of admission in hospitals will be covered as inpatient services. This provision applies when the patient receives all the services, including emergency room and observation services, at the same hospital. The following exceptions apply:

(1) When a patient's medicaid coverage changes payer sources (fee-for-service or managed care) on the date of the inpatient admission, all outpatient services provided within three calendar days prior to the inpatient admission will be submitted to the payer source responsible for those dates of service. The inpatient claim will be submitted to the payer source in effect on the date of admission.

(2) When a patient is admitted under the inpatient hospital services program (IHSP) benefit plan, all outpatient services provided by either the same hospital or a different hospital prior to the inpatient admission will not be included on the inpatient claim, with the exception of any outpatient services provided on the date of admission, which will be included on the inpatient hospital claim if provided at the same facility as the inpatient admission.

(H) "Medically necessary services" means services as defined in rule 5160-1-01 of the Administrative Code.

(I) "Observation services" means services furnished in an outpatient hospital setting, including the use of a bed and periodic monitoring by a hospital's nursing or other staff, which are reasonable and necessary to evaluate a patient's condition or determine the need for possible admission to the hospital as an inpatient.

(J) "Outpatient" is a patient who is not admitted as an inpatient and who receives outpatient services at a hospital or at a hospital's off-site unit that has been extended accreditation by the "Joint Commission," the "American Osteopathic Association," or is certified under medicare. Outpatient includes a patient admitted as an inpatient whose inpatient stay does not extend beyond midnight of the day of admission except in instances when, on the day of admission, a patient dies or is transferred to an inpatient psychiatric facility within the same hospital, to another hospital, or to a state psychiatric facility.

(K) "Outpatient services" means diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a practitioner of physician services to a patient by a hospital. Outpatient services do not include direct-care services provided by a practitioner of physician services as defined in paragraph (L) of this rule.

(L) "Practitioner of physician services" is a physician, podiatrist, dentist, clinical nurse specialist, certified nurse-midwife, certified nurse practitioner, or physician assistant.

(M) "Principal diagnosis" means the diagnosis established after study to be chiefly responsible for causing the patient's admission to the hospital.

(N) "Readmission" means an admission to the same institution within thirty days of discharge for hospitals paid under the Ohio department of medicaid's prospective payment system, as described in rule 5160-2-65 of the Administrative Code.

(O) "Transfer" is a patient who:

(1) Is moved from one eligible hospital's inpatient or outpatient department to another eligible hospital's inpatient or outpatient department, including state psychiatric facilities;

(2) Is moved from an eligible hospital to the same hospital's inpatient psychiatric facility; or

(3) Is moved to an eligible hospital from the same hospital's inpatient psychiatric facility.

Last updated July 12, 2024 at 9:40 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 1/1/2027
Prior Effective Dates: 12/21/1977, 12/29/1983, 9/3/1991 (Emer.), 7/1/1992, 12/29/1995 (Emer.)

Rule 5160-2-03 | Conditions and limitations.

• Effective: March 1, 2022
• Promulgated Under: 119.03

(A) Conditions and limitations applicable to both inpatient and outpatient hospital services.

(1) Coverage of provider-based physician services reimbursable as an inpatient or outpatient hospital service is limited to those services reimbursable under medicare, part A, except as provided in rule 5160-4-01 of the Administrative Code.

(2) The following inpatient or outpatient services related to the provision of the services described in this rule are not covered:

(a) Abortions other than those that meet the criteria for coverage set forth in rule 5160-17-01 of the Administrative Code.

(b) Sterilizations and hysterectomies other than those that meet the criteria for coverage set forth in Chapter 5160-21 of the Administrative Code.

(c) Artificial insemination, treatment of infertility, including procedures for reversal of voluntary sterilization.

(d) Plastic or cosmetic surgery when the surgery is performed for aesthetic purposes; for example, rhinoplasty, ear piercing, mammary augmentation or reduction, tattoo removal, excision of keloids, facioplasty, osteoplasty (prognathism and micrognathism), dermabrasion, skin grafts, and lipectomy.

(e) Gender transformation.

(f) Acupuncture, with the exception of conditions described in rule 5160-8-51 of the Administrative Code.

(g) Services of a research nature or services that are experimental and not in accordance with customary standards of medical practice or are not commonly used.

(h) Dental procedures unless:

(i) The nature of the surgery or the condition of the patient precludes performing the procedure in the dentist's office or other non hospital outpatient setting and the inpatient or outpatient service is a medicaid covered service.

(ii) The service was an emergency dental procedure performed in the emergency room.

(i) Patient convenience items.

(j) Pregnancy related services pertaining to a pregnancy that is a result of a contract for surrogacy services. For the purposes of this rule, "surrogacy services" means a woman agrees to become pregnant for the purpose of gestating and giving birth to a child she will not raise, but hand over to a contracted party.

(3) Blood and blood components--The department encourages the use of replacement blood donated on behalf of the recipient. However, the medicaid program will cover the cost of all blood administered, equivalent quantities of packed red blood cells or plasma when not available to the recipient from other sources, and the administering of replacement blood.

(4) Services related to covered organ donations are reimbursable when the recipient of a transplant is medicaid eligible.

(B) Conditions and limitations applicable to inpatient services only.

(1) Accommodations--The medicaid program covers semiprivate accommodations.

(a) Private rooms are covered only when the patient's condition necessitates isolation to protect the patient's health or the health of others.

(b) When no semiprivate rooms are available, the private room will be reimbursed as semiprivate rooms.

(c) For hospitals paid on a DRG prospective payment basis as identified in rule 5160-2-65 of the Administrative Code, private rooms will be excluded for purposes of determining outliers.

(d) For hospitals paid on a non-DRG prospective payment basis as identified in rule 5160-2-05 of the Administrative Code, private rooms are not covered and, accordingly, will not be reimbursed.

(2) Covered days --In general, medicaid covers only those days of care that are medically necessary or otherwise within certain limits as follows.

(a) The number of days of care charged by a hospital are to be reported in units of full days.

(i) The day of admission counts as a full day.

(ii) The day of discharge is not counted as a covered day, but charges for any covered services other than those described in revenue center codes 0100-0219 are covered for the days on which the services were rendered, not for the days the charges were posted.

(b) Late discharge--The medicaid program will not pay for a patient's continued stay beyond the checkout time because of personal reasons on the part of the patient or because of physician negligence.

(c) Leave of absence--The day on which a patient begins a leave of absence cannot be counted as a covered day unless the patient returns to the hospital prior to midnight of the same day.

(d) Days waiting for placement and custodial care--Coverage is not available for hospital inpatients for whom acute short-term hospital care is no longer necessary. This includes days waiting for transfer to a long-term care facility, days of inpatient care due to unnecessary delays in applying for court-ordered commitment, grace periods, administrative days, and custodial care. For purposes of this rule, "custodial care" is defined as maintenance, rather than curative care, on an indefinite basis, while grace periods and administrative days relate to days of care while waiting for placement elsewhere. This exclusion also applies to days spent as an inpatient at a transferring hospital on or after the effective date of a court commitment to another facility and inpatient days resulting from a hospital's failure to timely request or perform necessary diagnostic studies, medical-surgical procedures, or consultations.

(e) Reimbursement for medicaid inpatient hospital services for the treatment of persons whose principal diagnosis is a mental health disorder, will only be made to facilities that are licensed by the department of mental health and addiction services in accordance with Chapter 5122-14 of the Administrative Code.

(f) For hospitals paid on a DRG prospective payment basis as identified in rule 5160-2-65 of the Administrative Code, the non covered days of inpatient stay described in paragraphs (B)(2)(a) to (B)(2)(e) of this rule will be excluded for purposes of determining outliers in accordance with rule 5160-2-65 of the Administrative Code.

(g) For hospitals paid on a non-DRG prospective payment basis as identified in rule 5160-2-05 of the Administrative Code, the non covered days of inpatient stay described in paragraphs (B)(2)(a) to (B)(2)(e) of this rule, including associated inpatient services, are not covered and, accordingly, are not reimbursable.

(3) Surgical treatment for obesity is covered when prior authorized.

(C) Coverage conditions and limitations applicable to hospitals eligible to provide services pursuant to paragraphs (B) and (D) of rule 5160-2-01 of the Administrative Code.

(1) Coverage of inpatient services provided in hospitals to eligible recipients will be provided in accordance with Chapter 5122-14 of the Administrative Code or section 5119.33 of the Revised Code.

(2) Outpatient services provided in hospitals to eligible recipients will be provided in accordance with rule 5160-2-76 of the Administrative Code.

Last updated March 1, 2022 at 8:31 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 3/1/2027
Prior Effective Dates: 12/30/1977, 12/29/1983, 10/1/1984, 7/1/1990, 10/1/2003

Rule 5160-2-04 | Coverage of hospital-provided pharmaceutical, dental, vision care, medical supply and equipment, and medically-related transportation services.

• Effective: March 1, 2022
• Promulgated Under: 119.03

(A) Drugs.

(1) Drugs are classified as: administered inpatient (drugs administered to a patient while an inpatient); administered outpatient (drugs administered to a patient at the hospital in connection with outpatient services); take-home (drugs dispensed on an outpatient basis for use away from the hospital).

(2) Administered inpatient drugs are considered inpatient services and are reimbursed as an inpatient service. Administered outpatient drugs are considered outpatient services and are reimbursed as an outpatient hospital service in accordance with rule 5160-2-75 of the Administrative Code. Take-home drugs will be billed and reimbursed in accordance with provisions in Chapter 5160-9 of the Administrative Code.

(B) Medical supplies and equipment.

(1) Inpatient coverage:

(a) Supplies and equipment are covered for the care and treatment of the recipient during an inpatient stay and include:

(i) Implants and devices that are part of a surgical, immediate post surgical, or early fitting procedure (e.g., pacemakers, halos, and prosthetic devices);

(ii) Appliances that are generally applied prior to discharge (e.g., initial prostheses); and

(iii) Other items that are medically necessary as described in rule 5160-1-01 of the Administrative Code to permit or facilitate the patient's discharge from the hospital until such time as the recipient can obtain a permanent item or supply.

(b) Covered items should be included in the hospital's inpatient billing.

(c) Medical supplies and equipment provided to a medicaid recipient for use outside the hospital are reimbursed in accordance with Chapter 5160-10 of the Administrative Code.

(2) Outpatient coverage:

(a) Chapter 5160-10 of the Administrative Code describes the coverage and reimbursement of medical supplies provided during the provision of an outpatient visit

(b) Medical supplies and equipment provided to the medicaid recipient for use outside the hospital are reimbursed in accordance with Chapter 5160-10 of the Administrative Code.

(C) Dental services: Except for dental services described in rule 5160-2-03 of the Administrative Code and emergency dental services provided in the emergency room, all dental services are covered and reimbursed as dental services under the provisions set forth in Chapter 5160-5 of the Administrative Code.

(D) Vision care services: All vision care services are covered and reimbursed as inpatient or outpatient hospital services. All vision care materials are covered and reimbursed in accordance with the provisions of Chapter 5160-6 of the Administrative Code.

(E) Medically-related transportation services: The services of hospital staff as attendants during transportation are covered and reimbursed as an inpatient or outpatient hospital service. Transportation to or from a hospital, including inter hospital transfer, that is provided in accordance with Chapter 5160-15 of the Administrative Code is not a hospital service and is reimbursed as described in Chapter 5160-15 of the Administrative Code..

Last updated March 1, 2022 at 8:32 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03; 5164.02
Five Year Review Date: 3/1/2027
Prior Effective Dates: 10/1/1984, 8/1/2002, 11/1/2007, 4/30/2015

Rule 5160-2-05 | Classification of hospitals.

• Effective: May 11, 2023
• Promulgated Under: 119.03

This rule describes how hospitals are classified into mutually exclusive peer groups for purposes of setting rates and making payments under the "All Patient Refined-Diagnosis Related Group" (APR-DRG) inpatient prospective payment system, the "Enhanced Ambulatory Patient Grouping" (EAPG) outpatient prospective payment system or to those hospitals excluded from the prospective payment systems.

(A) Definitions.

(1) "Cancer hospitals" are those hospitals recognized by medicare that primarily treat neoplastic disease in accordance with 42 C.F.R. 412.23(f) effective October 1, 2022.

(2) "Children's hospitals" are those hospitals that primarily serve patients eighteen years of age and younger and that are excluded from medicare prospective payment in accordance with 42 C.F.R. 412.23(d) effective October 1, 2022, or are registered with the Ohio department of health in accordance with section 3701.07 of the Revised Code. A children's hospital that has less than seventy-five beds and enrolled as a medicaid provider on or after January 1, 2011, will:

(a) For the purposes of setting base rates, for inpatient services as described in rule 5160-2-65 of the Administrative Code and outpatient services as described in rule 5160-2-75 of the Administrative Code, be grouped into its natural rural or urban hospital peer group as described in paragraph (A)(7) or (A)(9) of this rule; and

(b) Receive any pricing considerations or differentials as if they were in the children's hospital peer group.

(3) "Critical access hospitals" (CAH) are those hospitals that are certified as a critical access hospital by the centers for medicare and medicaid services (CMS) and excluded from medicare prospective payment in accordance with 42 C.F.R. 400.202 effective October 1, 2022.

(4) "Freestanding long-term acute care hospitals" are those hospitals in which the department of health and human services has determined to be excluded from medicare prospective payment in accordance with 42 C.F.R. 412.23(e) effective October 1, 2022.

(5) ."Freestanding psychiatric hospitals" are those hospitals that are eligible to provide medicaid services as described in rule 5160-2-01 of the Administrative Code and are grouped into their natural peer group as defined in paragraphs (A)(2), (A)(3), (A)(7), (A)(8), and (A)(9) of this rule.

(6) "Freestanding rehabilitation hospitals" are those hospitals in which the department of health and human services has determined to be excluded from medicare prospective payment in accordance with 42 C.F.R. 412.23(b) effective October 1, 2022.

(7) "Rural hospitals" are those hospitals located in Ohio counties that are not classified into core based statistical areas (CBSA) as designated in the inpatient prospective payment system (IPPS) case-mix and wage index table as published by CMS for the federal fiscal year beginning in the calendar year immediately preceding the effective date of the hospital rates. A copy of the medicare IPPS case-mix and wage index table by CMS certification number (CCN) is available on the department's website at medicaid.ohio.gov.

(8) "Teaching hospitals" are those hospitals with a major teaching emphasis that have at least two hundred beds and have an intern-and resident-to-bed ratio of at least .35. For non-Ohio hospitals, only those hospitals classified by the Ohio department of medicaid (ODM) as teaching hospitals as of June 30, 2016, will be considered non-Ohio teaching hospitals.

(9) "Urban hospitals" are those hospitals located in Ohio counties that are classified into CBSAs as designated in the IPPS case-mix and wage index table as published by CMS for the federal fiscal year beginning in the calendar year immediately preceding the effective date of the hospital rates, and not otherwise defined in paragraphs (A)(2), (A)(3), (A)(7), and (A)(8) of this rule.

(10) For the purposes of this rule, the "number of beds" is the total number of beds reported on the hospital's state fiscal year (SFY) 2014 Ohio medicaid hospital cost report (ODM 02930, rev. 06/14).

(11) For the purposes of this rule, "interns and residents" is the net number of interns and residents reported on the hospital's SFY 2014 Ohio medicaid hospital cost report.

(B) Ohio hospital prospective payment peer groups.

(1) Hospitals described in paragraphs (B)(1)(a) to (B)(1)(e) of this rule will be paid on a prospective payment basis for inpatient services as described in rule 5160-2-65 of the Administrative Code and for outpatient services as described in rule 5160-2-75 of the Administrative Code.

(a) Critical access hospitals;

(b) Rural hospitals;

(c) Children's hospitals;

(d) Teaching hospitals;

(e) Urban hospitals, which are grouped based on geographical regions listed in the appendix to this rule.

(2) Hospitals described in paragraphs (B)(2)(a) to (B)(2)(c) of this rule will be paid in accordance with rule 5160-2-22 of the Administrative Code.

(a) Cancer hospitals;

(b) Rehabilitation hospitals;

(c) Long-term acute care hospitals.

(C) Reassignment of hospitals among peer groups.

On January first of each year, any hospital geographically located in an Ohio county that has been newly included or newly excluded from a CBSA, as designated in the IPPS case-mix and wage index table as published by CMS for the federal fiscal year beginning in the calendar year immediately preceding the effective date of the hospital rates, will be placed into either the rural peer group as defined in paragraph (A)(7) of this rule or, based on the geographical location of the hospital, an urban peer group as defined in paragraph (A)(9) of this rule, for the new classification. The hospital's new base rate will be the average cost per discharge of the new peer group without any consideration for hospital-specific risk provisions, as described in rule 5160-2-65 of the Administrative Code and rule 5160-2-75 of the Administrative Code, of either the new or previous peer group.

(D) Rates for new, acquired, replacement, and merged hospitals.

(1) Hospitals new to medicaid.

(a) Hospitals described in paragraph (B)(1) of this rule that are newly enrolled with medicaid, will be classified into mutually exclusive peer groups as defined in paragraph (A) of this rule. Until data is available to calculate hospital-specific rates, the hospital will receive:

(i) The base rate of the peer group in which they are classified into without any consideration for hospital-specific risk provisions as described in rule 5160-2-65 of the Administrative Code for inpatient services and rule 5160-2-75 of the Administrative Code for outpatient services,

(ii) The statewide average for capital allowance in accordance with rule 5160-2-66 of the Administrative Code, and

(iii) The statewide average for both inpatient cost-to-charge ratio and outpatient cost-to-charge ratio as described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

(b) Hospitals described in paragraph (B)(2) of this rule that are newly enrolled with medicaid, will receive ninety per cent of the calculated rates as described in paragraph (D)(1)(a)(iii) of this rule until data is available to calculate hospital-specific rates in accordance with rule 5160-2-22 of the Administrative Code.

(2) Acquired hospitals.

Hospitals that have a change of ownership will receive the prior owner's rates for reimbursement until a cost report is filed by the new owner in accordance with rule 5160-2-23 of the Administrative Code and rates are calculated in accordance with rule 5160-2-22 of the Administrative Code.

(3) Replacement hospitals.

If a new hospital facility is opened for the purpose of replacing an existing (original) hospital facility identifiable to a unique medicaid provider number and the original facility closes, the rates from the original facility will be used for reimbursement, if the conditions of paragraphs (C)(4)(a) to (C)(4)(c) of rule 5160-2-09 of the Administrative Code are met, and until a cost report is filed by the new owner in accordance with rule 5160-2-23 of the Administrative Code and rates are calculated in accordance with rule 5160-2-22 of the Administrative Code.

(4) Hospital mergers.

When hospitals identifiable by a unique medicaid provider number are involved in a merger, the rates for the surviving medicaid provider number will be used for reimbursement until a cost report is filed in accordance with rule 5160-2-23 of the Administrative Code and rates are calculated in accordance with rule 5160-2-22 of the Administrative Code.

View Appendix

Last updated May 11, 2023 at 8:23 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02, 5164.70
Five Year Review Date: 5/11/2028
Prior Effective Dates: 9/1/2018

Rule 5160-2-08 | Data policies for disproportionate share and indigent care adjustments for hospital services.

• Effective: June 13, 2016
• Promulgated Under: 119.03

This rule sets forth the data used to determine assessments and adjustments, and the data policies that are applicable for each program year for all providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code.

(A) Definitions.

(1) "Disproportionate share hospital" means a hospital that meets the requirements for disproportionate share status as defined in rule 5160-2-09 of the Administrative Code.

(2) "Governmental hospital" means a county hospital with more than five hundred beds or a state-owned and -operated hospital with more than five hundred beds.

(3) "Hospital" means a hospital that is described under section 5168.01 of the Revised Code.

(4) "Hospital care assurance program fund" means the fund described under section 5168.11 of the Revised Code.

(5) "Hospital care assurance match fund" means the fund described under section 5168.11 of the Revised Code.

(6) "Intergovernmental transfer" means any transfer of money by a governmental hospital.

(7) "Health care services administration fund" means the fund described under section 5162.54 of the Revised Code.

(8) "Program year" means the twelve-month period beginning on the first day of October and ending on the thirtieth day of September.

(9) "Total facility costs" for each hospital means the amount from the ODM 02930, "Ohio Medicaid Hospital Cost Report," for the applicable state fiscal year, schedule B, column 3, line 202. For non-medicaid participating hospitals, total facility costs shall be determined from the medicare cost report.

(10) "Total skilled nursing facility costs" for each hospital means the amount on the ODM 02930, schedule B, column 3, line 44. For non-medicaid participating hospitals, total skilled nursing facility costs shall be determined from the medicare cost report.

(11) "Total home health facility costs" for each hospital means the amount on the ODM 02930, schedule B, column 3, line 98. For non-medicaid participating hospitals, total home health facility costs shall be determined from the medicare cost report.

(12) "Total hospice facility costs" for each hospital means the amount on ODM 02930, schedule B, column 3, line 99. For non-medicaid participating hospitals, total hospice facility costs shall be determined from the medicare cost report.

(13) "Total ambulance costs" for each hospital means the amount on ODM 02930, schedule B, column 3, line 95. For non-medicaid participating hospitals, total ambulance costs shall be determined from the medicare cost report.

(14) "Total Durable Medical Equipment (DME) rental costs" for each hospital means the amount on ODM 02930, schedule B, column 3, line 96. For non-medicaid participating hospitals, total DME rental costs shall be determined from the medicare cost report.

(15) "Total DME sold costs" for each hospital means the amount on ODM 02930, schedule B, column 3, line 97. For non-medicaid participating hospitals, total DME sold costs shall be determined from the medicare cost report.

(16) "Other non-hospital costs" for each hospital means separately identifiable non-hospital operating costs found on worksheet B, Part I of the medicare cost report, as determined by the department upon the request of the hospital, that are permitted to be excluded from the provider tax in compliance with section 1903(w) of the Social Security Act.

(17) "Adjusted total facility costs" means the result of subtracting the sum of the amounts defined in paragraphs (A)(10), (A)(11), (A)(12), (A)(13), (A)(14) and (A)(15) of this rule from the amount defined in paragraph (A)(9) of this rule.

(B) Source data for calculations.

(1) The calculations described in this rule for each program year will be based on cost-reporting data described in rule 5160-2-23 of the Administrative Code that reflects the completed interim settled medicaid cost report (ODM 02930) for each hospital's cost reporting period ending in the state fiscal year that ends in the federal fiscal year preceding each program year. For non-medicaid participating hospitals, the calculations will be based on the medicare cost report for the same time period.

(a) For new hospitals, the first available cost report filed with the department in accordance with rule 5160-2-23 of the Administrative Code will be used until a cost report that meets the requirements of this paragraph is available. If, for a new hospital, there is no available or valid cost report filed with the department, the hospital will be excluded until valid data is available.

(b) Data for hospitals that have changed ownership shall be treated as described in paragraphs (B)(1)(b)(i) to (B)(1)(b)(ii) of this rule.

(i) For a change of ownership that occurs during the program year, the cost reporting data filed by the previous owner that reflects that hospital's most recent completed interim settled medicaid cost report shall be annualized to reflect one full year of operation. The data will be allocated to each owner based on the number of days in the program year the hospital was owned.

(ii) For a change of ownership that occurred in the previous program year, the cost reporting data filed by the previous owner that reflects that hospital's most recent completed interim settled medicaid cost report and the cost reporting data filed by the new owner that reflects that hospital's most recent completed interim settled medicaid cost report, will be combined and annualized by the department to reflect one full year of operation. If there is no available or valid cost report from the previous owner, the department shall annualize the cost report from the new owner to reflect one full year of operation.

(c) For hospitals involved in mergers during the program year that result in the hospitals using one provider number, the cost reports from the merged providers will be combined and annualized by the department to reflect one full year of operation.

Cost report data used in the calculations described in this rule will be the cost report data described in this paragraph and are subject to any adjustments made upon departmental review that is completed each year and subject to the provisions of paragraph (D) of this rule.

(2) Closed hospitals with unique medicaid provider numbers.

For a hospital facility, identifiable to a unique medicaid provider number, that closes during the current program year as defined in paragraph (A) of this rule, the cost report data shall be adjusted to reflect the portion of the year that the hospital was open during the current program year. That partial year data shall be used to determine the assessment owed by that closed hospital.

Hospitals identifiable to a unique medicaid provider number that closed during the immediate prior program year will not owe an assessment for the current program year.

(3) Replacement hospital facilities.

(a) If a new hospital facility is opened for the purpose of replacing an existing (original) hospital facility identifiable to a unique medicaid provider number and the original facility closes during the program year defined in paragraph (A) of this rule, the cost report data from the original facility shall be used to determine the assessment for the new replacement facility if the following conditions are met:

(i) Both facilities have the same ownership,

(ii) There is appropriate evidence to indicate that the new facility was constructed to replace the original facility,

(iii) The new replacement facility is so located as to serve essentially the same population as the original facility, and

(iv) The new replacement facility has not filed a cost report for the current program year.

(b) For a replacement hospital facility that opened in the immediate prior program year, the assessment for that facility will be based on the cost report data for that facility and the cost report data for the original facility, combined and annualized by the department to reflect one full year of operation.

(C) Deposits into the health care services administration fund.

From the first installment of assessments paid under rule 5160-2-08.1 of the Administrative Code and intergovernmental transfers made under rule 5160-2-08.1 of the Administrative Code during each program year, the department shall deposit into the state treasury to the credit of the health care services administration fund, a total amount equal to the amount allocated by the appropriations act from assessments paid under section 5168.06 of the Revised Code and intergovernmental transfers made under section 5168.07 of the Revised Code during each program year.

(D) Finalization of data used for disproportionate share and indigent care adjustments.

During each program year, the department may provide any data the department may choose to use for disproportionate share and indigent care adjustments, described in rule 5160-2-09 of the Administrative Code, to each hospital. The department may mail the data or may make the data available on the medicaid provider portal. The department will notify each hospital of the availability of the data via regular or electronic mail (e-mail). Not later than thirty days after the department mails or e-mails the notification, any hospital may submit to the department a written request to correct data. Any documents, data, or other information that supports the hospital's request to correct data must be submitted with the request. On the basis of the information submitted to the department, the department may adjust the data.

(1) For each program year, thirty-days after the expiration of all hospitals' thirty-day data correction periods, the department shall consider the data correction period closed and all data final, subject to review and acceptance by the department.

(2) Any hospital that requests to correct data after the expiration of its thirty-day correction period but before the data correction period is closed for all hospitals as described in paragraph (D)(1) of this rule, shall be subject to an administrative fee. The administrative late fee shall be 0.03 per cent of the hospital's adjusted total facility cost as calculated in paragraph (A)(17) of this rule. The hospital shall include payment of the administrative late fee with the written request to correct data.

(3) All amounts received by the department under this paragraph shall be deposited into the state treasury to the credit of the health care services administration fund, described under paragraph (A)(7) of this rule.

(4) The department shall accept at any time, data from any hospital that has misstated its reported data used to make disproportionate share and indigent care adjustments and that resulted in a disproportionate share and indigent care payment that was greater than the payment would have been with the corrected data.

(E) Confidentiality.

Except as specifically required by the provisions of this rule and rule 5160-2-24 of the Administrative Code, information filed shall not include any patient-identifying material. Information including patient-identifying information is not a public record under section 149.43 of the Revised Code and no patient-identifying material shall be released publicly by the department of medicaid or by any person under contract with the department who has access to such information.

Supplemental Information

Authorized By: 5168.02
Amplifies: 5168.02
Five Year Review Date: 6/13/2021
Prior Effective Dates: 6/26/1996 (Emer.), 8/13/1996, 7/24/1997 (Emer.), 8/26/1999, 7/18/2000 (Emer.)

Rule 5160-2-08.1 | Assessment rates.

• Effective: November 11, 2018
• Promulgated Under: 119.03

(A) Applicability.

The requirements of this rule apply as long as the United States centers for medicare and medicaid services (CMS) determines that the assessment imposed under section 5168.06 of the Revised Code is a permissible health care related tax. Whenever the department of medicaid is informed that the assessment is an impermissible health care-related tax, the department shall promptly refund to each hospital the amount of money currently in the hospital care assurance match fund that has been paid by the hospital, plus any investment earnings on that amount.

(B) Definitions

(1) "Program year" - The period beginning the first day of October of a calendar year and ending on the thirtieth day of September of the following calendar year.

(2) "Current program year" - The program year beginning the first day of October of the most recent calendar year and ending on the thirtieth day of September the following calendar year.

(3) "Past program year" - Any program year beginning the first day of October in a calendar year preceding the current program year and ending the thirtieth day of September the following calendar year.

(C) The program years to which this rule applies are identified in paragraphs (C)(1) to (C)(3) of this rule. When the department is notified by the CMS that an additional disproportionate share allotment is available for a past program year, the department may amend the assessment rates for the past program year.

(1) The assessment rates applicable to the current program year are specified in paragraph (D) of this rule.

(2) The assessment rates applicable to the past program year when federal allotment is increased are specified in paragraph (E)(1) of this rule.

(3) The revised assessment rates applicable to the past program year when federal allotment is decreased are specified in paragraph (E)(2) of this rule.

(D) Calculation of assessment amounts.

The calculations described in this rule will be based on the cost-reporting data described in rule 5160-2-23 of the Administrative Code that reflect the most recently completed interim settled medicaid cost report for all hospitals. For non-medicaid participating hospitals, the calculations shall be based on the most recent as-filed medicare cost report.

The assessment is calculated as follows:

(1) Determine each hospital's adjusted total facility costs as the amount calculated in paragraph (A)(17) of rule 5160-2-08 of the Administrative Code.

(2) For hospitals with adjusted total facility costs, as described in paragraph (D)(1) of this rule, that are less than or equal to $216,372,500, multiply the hospital's adjusted total facility costs as described in paragraph (D)(1) of this rule by one and one half per cent. The product will be each hospital's assessment amount. For hospitals with adjusted total facility costs, as described in paragraph (D)(1) of this rule, that are greater than $216,372,500, multiply a factor of one and one half per cent times the hospital's adjusted total facility costs as described in paragraph (D)(1) of this rule, up to $216,372,500. Multiply a factor of one per cent times the hospital's adjusted total facility costs as described in paragraph (D)(1) of this rule, that are in excess of $216,372,500. The sum of the two products will be each hospital's assessment amount.

(3) The assessment amounts calculated in paragraph (D)(2) of this rule are subject to adjustment under the provisions of paragraph (G) of this rule.

(4) The department may establish a rate lower than the rates described in paragraph (D)(2) of this rule based on the assessment necessary to maximize the disproportionate share allotment for the current program year.

(E) Federal allotment adjustment.

(1) For past program years in which the federal disproportionate share allotment has increased, the department shall recalculate the assessment rate for that program year and notify each hospital via rate letter of the additional amount to be paid by the hospital to collect the state share necessary to expend the additional allotment. The adjusted assessment rate described in this paragraph will be calculated in accordance with paragraph (D) of this rule. The assessment collected will then be matched with federal funds and distributed to hospitals based upon the distribution model for the applicable past program year. Notwithstanding paragraph (D)(3) of this rule, the provisions outlined in paragraph (G)(2) of this rule are not applicable to any past program year.

(2) When the department is notified by the CMS of a decrease in the federal disproportionate share allotment for a past program year, the department shall recalculate the distribution for that program year and notify each hospital via recoupment letter of the amount to be recouped. Of the total amount recouped, the portion that was funded with federal funding shall be returned to the CMS. The portion of the recoupment that is state funds shall be applied toward the required assessment for a future program year. Notwithstanding paragraph (D)(3) of this rule, the provisions outlined in paragraph (G)(2) of this rule are not applicable to any past program year.

(F) Determination of intergovernmental transfer amounts.

The department may require governmental hospitals, as described in paragraph (A)(2) of rule 5160-2-08 of the Administrative Code, to make intergovernmental transfers each program year.

The department shall notify each governmental hospital of the amount of the intergovernmental transfer it is required to make during the program year.

Each governmental hospital shall make intergovernmental transfers in periodic installments, executed by electronic funds transfer.

(G) Notification and reconsideration procedures.

(1) The department shall mail by certified mail, return receipt requested, the results of the determinations made under paragraphs (D) and (E) of this rule to each hospital. If no hospital submits a request for reconsideration as described in paragraph (G)(2) of this rule, the preliminary determinations constitute the final reconciliation of the amounts that each hospital must pay under this rule.

(2) Not later than fourteen days after the department mails the preliminary determinations as described in paragraphs (D) and (E) of this rule, any hospital may submit to the department a written request for reconsideration of the preliminary determination made under paragraphs (D) and (E) of this rule. The request must be accompanied by written materials setting forth the basis for the reconsideration.

If one or more hospitals submit such a request, the department shall hold a public hearing in Columbus, Ohio not later than thirty days after the preliminary determinations have been mailed by the department for the purpose of reconsidering its preliminary determinations. The department shall mail written notice of the date, time, and place of the hearing to every hospital at least ten days before the date of the hearing.

On the basis of the evidence submitted to the department or presented at the public hearing, the department shall reconsider and may adjust the preliminary determinations. The result of the reconsideration is the final reconciliation of the amounts that each hospital must pay under the provisions of this rule.

(3) The department shall mail each hospital written notice of the amount it must pay under the final reconciliation as soon as practical. Any hospital may appeal the amount it must pay to the court of common pleas of Franklin county.

(4) In the course of any program year, the department may adjust the assessment rate defined in paragraphs (D) and (E) of this rule or adjust the amount of the intergovernmental transfers required under paragraph (F) of this rule, and, as a result of the adjustment, adjust each hospital's assessment and intergovernmental transfer, to reflect refinements made by the CMS during that program year.

Supplemental Information

Authorized By: 5168.02, 5168.06
Amplifies: 5168.02, 5168.06, 5168.07, 5168.08
Five Year Review Date: 1/1/2022
Prior Effective Dates: 7/1/1994, 8/13/1996, 4/16/1999 (Emer.), 6/10/1999 (Emer.), 7/18/2000 (Emer.), 7/1/2002 (Emer.), 9/17/2007, 12/25/2010, 11/28/2012 (Emer.), 1/1/2017

Rule 5160-2-09 | Payment policies for disproportionate share and indigent care adjustments for hospital services.

• Effective: November 11, 2018
• Promulgated Under: 119.03

This rule is applicable for each program year for all medicaid-participating providers of hospital services included in the definition of "hospital" as described under section 5168.01 of the Revised Code.

(A) Definitions.

(1) "Total fee for service (FFS) medicaid costs" for each hospital means the sum of inpatient program costs reported on ODM 02930, schedule H, section I, columns 1 and 3, line 1 and outpatient medicaid program costs as reported on ODM 02930, "Ohio Medicaid Hospital Cost Report," section II, column 1, line 10 for the applicable state fiscal year.

(2) "Total medicaid managed care plan (MCP) inpatient costs" for each hospital means the amount on ODM 02930 schedule I, column 3, line 202.

(3) "Total medicaid MCP outpatient costs" for each hospital means the amount on ODM 02930 schedule I, column 5, line 202.

(4) "Total Title V costs" for each hospital means the sum of the inpatient and outpatient program costs as reported on ODM 02930, schedule H, section I, column 2, line 1 and section II, column 2, line 10.

(5) "Total inpatient uncompensated care costs for people without insurance" for each hospital means the sum of the inpatient uncompensated care costs below the poverty level and inpatient uncompensated care costs above the poverty level amounts as totaled on ODM 02930, schedule F, column 5.

(6) "Total inpatient uncompensated care costs under one hundred per cent" for each hospital means the sum of the inpatient uncompensated care costs under one hundred per cent for patients with and without insurance as reported on the ODM 02930, schedule F, columns 4 and 5.

(7) "Total inpatient uncompensated care costs above one hundred per cent without insurance" for each hospital means the sum of the inpatient uncompensated care costs over one hundred per cent for patients without insurance as reported on the ODM 02930, schedule F, column 5.

(8) "Total outpatient uncompensated care costs under one hundred per cent" for each hospital means the sum of the outpatient care costs under one hundred per cent for patients with and without insurance as on the ODM 02930, schedule F, columns 4 and 5.

(9) "Total outpatient uncompensated care costs above one hundred per cent without insurance" for each hospital means the sum of the outpatient uncompensated care costs above one hundred per cent for patients without insurance as reported on the ODM 02930, schedule F, column 5.

(10) "Total uncompensated care costs under one hundred per cent" for each hospital means the sum of total inpatient uncompensated care costs under one hundred per cent as described in paragraph (A)(6) of this rule, and total outpatient uncompensated care costs under one hundred per cent as described in paragraph (A)(8) of this rule.

(11) "Total uncompensated care costs above one hundred per cent without insurance" for each hospital means the sum of total inpatient uncompensated care costs above one hundred per cent without insurance as described in paragraph (A)(7) of this rule, and total outpatient uncompensated care costs above one hundred per cent without insurance as described in paragraph (A)(9) of this rule.

(12) "Total outpatient uncompensated care costs for people without insurance" for each hospital means the sum of the outpatient uncompensated care costs below the poverty level and outpatient uncompensated care costs above the poverty level as represented on the ODM 02930, schedule F.

(13) "Total uncompensated care costs for patients without insurance" for each hospital means the sum of the total inpatient uncompensated care costs for people without insurance in paragraph (A)(5) of this rule and the total outpatient uncompensated care costs for people without insurance in paragraph (A)(12) of this rule.

(14) "Total FFS medicaid days" means, for each hospital, the amount on the ODM 02930, schedule C, column 6, line 49.

(15) "MCP days" mean for each hospital, the amount on the ODM 02930, schedule I, column 2, line 204.

(16) "Total medicaid days" for each hospital means the sum of total medicaid FFS days as defined in paragraph (A)(14) of this rule and MCP days as defined in (A)(15) of this rule.

(17) "High federal disproportionate share hospital" means a hospital with a ratio of total medicaid days as defined in paragraph (A)(16) of this rule to total facility days as defined in paragraph (A)(19) of this rule greater than the statewide mean ratio of the sum of total medicaid days to the sum of total facility days plus one standard deviation.

(18) "Total medicaid FFS payments" for each hospital means the sum of the total medicaid inpatient payments, total medicaid outpatient payments, and the medicaid settlement amounts as reported on the ODM 02930, schedule H, column 1, lines 7, 15, and 26.

(19) "Total facility days" means for each hospital the amount reported on the ODM 02930, schedule C, column 4, line 49.

(20) "Medicaid utilization rate" for each hospital means the rate calculated by dividing the sum of total medicaid days as defined in paragraph (A)(16) of this rule by the total facility days as defined in paragraph (A)(19) of this rule.

(21) "Total medicaid MCP costs" for each hospital means the actual cost to the hospital of care rendered to medical assistance recipients enrolled in a MCP that has entered into a contract with the department of medicaid and is the amount on ODM 02930, schedule I, column 3, line 202 and column 5, line 202.

(22) "Medicaid MCP inpatient payments" for each hospital means the amount on ODM 02930 schedule I, column 2, line 208.

(23) "Medicaid MCP outpatient payments" for each hospital means the amount on ODM 02930 schedule I, column 4, line 208.

(24) "Total medicaid MCP payments" for each hospital is the sum of the amount calculated in paragraph (A)(22) of this rule, and the amount calculated in paragraph (A)(23) of this rule.

(25) "Adjusted total facility costs" for each hospital means the amount described in paragraph (A) of rule 5160-2-08 of the Administrative Code.

(26) "Rural Hospital (RH)" means a hospital geographically located in an Ohio county that is not classified into a core based statistical area (CBSA) as designated in the inpatient prospective payment system (IPPS) case-mix and wage index table as published October first of each program year by the centers for medicare and medicaid services (CMS).

(27) "Critical Access Hospital (CAH)" means a hospital that is certified as a critical access hospital by CMS and that has notified the Ohio department of health and the Ohio department of medicaid of such certification. The Ohio department of medicaid must receive notification of critical access hospital certification by the first day of October, the start of the program year, in order for the hospital to be considered a critical access hospital for disproportionate share payment purposes. Hospitals shall notify the Ohio department of medicaid of any change in their critical access hospital status, including continued CAH designations, immediately following notification from CMS.

(28) "Hospital-specific disproportionate share limit" for each hospital means the limit on disproportionate share and indigent care payments made to a specific hospital as defined in paragraph (J)(2) of this rule.

(29) "Children's hospitals" are those hospitals that meet the definition in paragraph (A)(3) of rule 5160-2-05 of the Administrative Code.

(30) "Inpatient upper limit payment" for each hospital means the amount reported on ODM 02930, schedule H, section I, column 1, line 5.

(31) "Outpatient upper limit payment" for each hospital means the amount reported on ODM 02930, schedule H, section II, column 1, line 14.

(32) "Total program amount" means the sum of the amounts in paragraphs (K)(2) and (K)(3) of this rule.

(33) "Obstetric services requirements (OSR)" means for each hospital that satisfies the federal statute of having at least two obstetricians who have staff privileges at the hospital that agreed to provide obstetric services to medicaid eligible individuals during the cost-reporting year as defined in paragraph (B) of rule 5160-2-08 of the Administrative Code. For rural hospitals as defined in paragraph (A))(26) of this rule, this requirement includes any physician with staff privileges at the hospital to perform non-emergency obstetric procedures. This requirement shall not apply to a hospital whose inpatients are predominantly individuals under eighteen years of age or a hospital which did not offer non-emergency obstetric services to the general population as of December 22, 1987, the date the federal statute was enacted.

(B) Applicability.

The requirements of this rule apply as long as CMS determines that the assessment imposed under section 5168.06 of the Revised Code is a permissible health care related tax. Whenever the department of medicaid is informed that the assessment is an impermissible health care-related tax, the department shall promptly refund to each hospital the amount of money currently in the hospital care assurance program fund that has been paid by the hospital, plus any investment earnings on that amount.

(C) Source data for calculations.

(1) The calculations described in this rule will be based on cost-reporting data described in paragraph (B)(1) of rule 5160-2-08 of the Administrative Code.

(2) For new hospitals, the first available cost report filed with the department in accordance with rule 5160-2-23 of the Administrative Code will be used until a cost report that meets the requirements of this paragraph is available. If, for a new hospital, there is no available or valid cost report filed with the department, the hospital will be excluded until valid data is available.

Cost reports for hospitals involved in mergers during the program year that result in the hospitals using one provider number will be combined and annualized by the department to reflect one full year of operation.

(3) Closed hospitals with unique medicaid provider numbers.

For a hospital facility, identifiable to a unique medicaid provider number, that closes during the program year defined in paragraph (A) of rule 5160-2-08 of the Administrative Code, the cost report data used shall be adjusted to reflect the portion of the year the hospital was open during the current program year. That partial year data shall be used to determine the distribution to that closed hospital. The difference between the closed hospital's distribution based on the full year cost report and the partial year cost report shall be redistributed to the remaining hospitals in accordance with paragraph (G) of this rule.

For a hospital facility identifiable to a unique medicaid provider number that closed during the immediate prior program year, the cost report data shall be used to determine the distribution that would have been made to that closed hospital. This amount shall be redistributed to the remaining hospitals in accordance with paragraph (G) of this rule.

(4) Replacement hospital facilities.

If a new hospital facility is opened for the purpose of replacing an existing (original) hospital facility identifiable to a unique medicaid provider number and the original facility closes during the program year defined in paragraph (A) of rule 5160-2-08 of the Administrative Code, the cost report data from the original facility shall be used to determine the distribution to the new replacement facility if the following conditions are met:

(a) Both facilities have the same ownership,

(b) There is appropriate evidence to indicate that the new facility was constructed to replace the original facility,

(c) The new replacement facility is so located as to serve essentially the same population as the original facility, and

(d) The new replacement facility has not filed a cost report for the current program year.

For a replacement hospital facility that opened in the immediate prior program year, the distribution for that facility will be based on the cost report data for that facility and the cost report data for the original facility, combined and annualized by the department to reflect one full year of operation.

(5) Hospitals that have changed ownership.

For a change of ownership that occurs during the program year, the cost reporting data filed by the previous owner that reflects that hospital's most recent completed interim settled medicaid cost report shall be annualized to reflect one full year of operation. The data will be allocated to each owner based on the number of days in the program year the hospital was owned.

For a change of ownership that occurred in the previous program year, the cost reporting data filed by the previous owner that reflects that hospital's most recent completed interim settled medicaid cost report and the cost reporting data filed by the new owner that reflects that hospital's most recent completed interim settled medicaid cost report, will be combined and annualized by the department to reflect one full year of operation. If there is no available or valid cost report from the previous owner, the department shall annualize the cost report from the new owner to reflect one full year of operation.

(6) Cost report data used in the calculations described in this rule will be the cost report data described in this paragraph subject to any adjustments made upon departmental review prior to final determination that is completed each year and subject to the provisions of rule 5160-2-08 of the Administrative Code.

(D) Determination of indigent care pool.

(1) The "indigent care pool" means the sum of the following:

(a) The total assessments paid by all hospitals less the assessment deposited into the health care services administration fund described in rule 5160-2-08 of the Administrative Code.

(b) The total amount of intergovernmental transfers required to be made by governmental hospitals less the amount of the transfer deposited into the health care services administration fund described in rule 5160-2-08 of the Administrative Code.

(c) The total amount of federal matching funds that will be made available to general acute care hospitals in the same program year as a result of the state's disproportionate share limit payment allotment determined by the CMS for that program year.

(2) The funds available in the indigent care pool shall be distributed through policy payment pools in accordance with paragraphs (E) to (I) of this rule. Policy payment pools shall be allocated a percentage of the indigent care pool as described in paragraphs (D)(2)(a) to (D)(2)(e) of this rule.

(a) High federal disproportionate share hospital pool: 12.00 per cent.

(b) Medicaid indigent care pool: 77.26 per cent.

(c) Uncompensated care pool below one hundred per cent of poverty: zero per cent.

(d) Critical access and rural hospitals: 8.76 per cent.

(e) Children's hospitals: 1.98 per cent.

(E) Distribution of funds through the indigent care payment pools.

The funds are distributed among the hospitals according to indigent care payment pools described in paragraphs (E)(1) to (E)(3) of this rule.

(1) Hospitals meeting the high federal disproportionate share hospital definition described in paragraph (A)(17) of this rule shall receive funds from the high federal disproportionate share indigent care payment pool.

(a) For each hospital that meets the high federal disproportionate share definition, calculate the ratio of the hospital's total FFS medicaid costs and total medicaid MCP costs to the sum of total FFS medicaid costs and total medicaid MCP costs for all hospitals that meet the high federal disproportionate share definition.

(b) For each hospital that meets the high federal disproportionate share definition, multiply the ratio calculated in paragraph (E)(1)(a) of this rule by the amount allocated in paragraph (D)(2)(a) of this rule to determine each hospital's high federal disproportionate share hospital payment amount, subject to the following limitations:

(i) If the hospital's payment amount calculated in paragraph (E)(1)(b) of this rule is greater than or equal to its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's high federal disproportionate share hospital payment is the amount defined in paragraph (A)(28).

(ii) If the hospital's payment amount calculated in (E)(1)(b) of this rule is less than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's high federal disproportionate share hospital payment is equal to the amount in paragraph (E)(1)(b) of this rule and any additional amount provided by paragraph (E)(1)(b)(iv) of this rule.

(iii) If the hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule is equal to or less than zero, the hospital's high federal disproportionate share hospital payment is equal to zero.

(iv) For hospitals whose high federal disproportionate share hospital payment is set at the disproportionate share limit defined in paragraph (A)(28) of this rule, calculate each hospital's limited payment by subtracting the amount defined in paragraph (A)(28) of this rule from the amount determined in paragraph (E)(1)(b) of this rule and sum these amounts for all limited hospital(s). Subtract the sum of the limited payments from the amount allocated in paragraph (D)(2)(a) of this rule and repeat the distribution described in paragraph (E)(1) of this rule until all remaining funds for this pool are expended.

(2) Hospitals shall receive funds from the medicaid indigent care payment pool.

(a) For each hospital, subtract the amount distributed in paragraph (E)(1) of this rule from the hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule.

(b) For all hospitals, sum the amounts calculated in paragraph (E)(2)(a) of this rule.

(c) For each hospital, calculate the ratio of the amount in paragraph (E)(2)(a) of this rule to the amount in paragraph (E)(2)(b) of this rule.

(d) For each hospital, multiply the ratio calculated in paragraph (E)(2)(c) of this rule by the amount allocated in paragraph (D)(2)(b) of this rule to determine each hospital's medicaid indigent care payment amount subject to the following limitations:

(i) If the sum of a hospital's payment amounts calculated in paragraph (E)(1) of this rule is greater than or equal to its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's medicaid indigent care payment pool amount is equal to zero.

(ii) If the sum of a hospital's payment amounts calculated in paragraphs (E)(1) and (E)(2)(d) of this rule is less than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, then the payment is equal to the amount in paragraph (E)(2)(d) of this rule and any amount provided by paragraph (E)(2)(d)(iv) of this rule.

(iii) If the sum of a hospital's payment amounts calculated in paragraphs (E)(1) and (E)(2)(d) of this rule is greater than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, then the payment is equal to the difference between the hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule and the amount calculated in paragraph (E)(1) of this rule.

(iv) If any hospital is limited as described in paragraph (E)(2)(d)(iii) of this rule, calculate each hospital's limited payment by subtracting the amount defined in paragraph (A)(28) of this rule from the amount determined in paragraph (E)(2)(d) of this rule and sum these amounts for all limited hospital(s). Subtract the sum of the limited payments from the amount allocated in paragraph (D)(2)(b) of this rule and repeat the distribution described in paragraph (E)(2) of this rule until all remaining funds for this pool are expended.

(v) For all hospitals, sum the amounts calculated in paragraph (E)(2)(d) of this rule. This amount is the hospital's medicaid indigent payment amount.

(3) Hospitals shall receive funds from the uncompensated care indigent care payment pool.

(a) For each hospital, sum total inpatient uncompensated care costs under one hundred per cent defined in paragraph (A)(6) of this rule and total outpatient uncompensated care costs under one hundred per cent defined in paragraph (A)(8) of this rule. For hospitals with total negative uncompensated care costs, the resulting sum is equal to zero.

(b) For all hospitals, sum the amounts calculated in paragraph (E)(3)(a) of this rule.

(c) For each hospital, calculate the ratio of the amount in paragraph (E)(3)(a) of the rule to the amount in paragraph (E)(3)(b) of this rule.

(d) For each hospital, multiply the ratio calculated in paragraph (E)(3)(c) of this rule by the amount allocated in paragraph (D)(2)(c) of this rule to determine each hospital's uncompensated care under one hundred per cent payment, subject to the following limitations:

(i) If the sum of a hospital's payment amounts calculated in paragraphs (E)(1) and (E)(2) of this rule is greater than or equal to its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's uncompensated care under one hundred per cent payment amount is equal to zero.

(ii) If the sum of a hospital's payment amount calculated in paragraphs (E)(1) and (E)(2) of this rule and the amount calculated in paragraph (E)(3)(d) of this rule is less than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's uncompensated care under one hundred per cent payment amount is equal to the amount calculated in paragraph (E)(3)(d) of this rule and any amount provided by paragraph (E)(3)(d)(iv) of this rule.

(iii) If a hospital does not meet the condition described in paragraph (E)(3)(d)(i) of this rule, and the sum of its payment amounts calculated in paragraphs (E)(1) and (E)(2) of this rule and the amount calculated in paragraph (E)(3)(d) of this rule is greater than its hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's uncompensated care under one hundred per cent payment amount is equal to the difference between the hospital's disproportionate share limit and the sum of the payment amounts calculated in paragraphs (E)(1) and (E)(2) of this rule.

(iv) If any hospital is limited as described in paragraph (E)(3)(d)(iii) of this rule, calculate each hospital's limited payment by subtracting the amount defined in paragraph (A)(28) of this rule from the amount determined in paragraph (E)(3)(d) of this rule and sum these amounts for all limited hospital(s). Subtract the sum of the limited payments from the amount allocated in paragraph (D)(2)(c) of this rule and repeat the distribution described in paragraph (E)(3) of this rule until all funds for this pool are expended.

(e) For each hospital, sum the amount calculated in paragraph (E)(3)(d) of this rule. This amount is the hospital's uncompensated care indigent care payment amount.

(F) Distribution of funds through the rural and critical access payment pools.

The funds are distributed among the hospitals according to rural and critical access payment pools described in paragraphs (F)(1) to (F)(2) of this rule.

(1) Hospitals meeting the definition described in paragraph (A)(27) of this rule, shall receive funds from the critical access hospital (CAH) payment pool.

(a) For each hospital with CAH certification, calculate the remaining hospital-specific disproportionate share limit by subtracting the amounts calculated in paragraphs (E)(1), (E)(2) and (E)(3) of this rule from the amount described in paragraph (A)(28) of this rule.

(b) For each hospital with CAH certification:

(i) Calculate the ratio of each CAH hospital's remaining hospital-specific disproportionate share limit as described in paragraph (F)(1)(a) of this rule to the total remaining hospital-specific disproportionate share limit for all CAH hospitals.

(ii) For each CAH hospital, multiply the ratio calculated in paragraph (F)(1)(b)(i) of this rule by 38.81 per cent of the amount allocated in paragraph (D)(2)(d) of this rule to determine each hospital's CAH payment amount.

(c) For all hospitals with CAH certification, sum the amounts calculated in paragraph (F)(1)(b) of this rule.

(d) For each hospital with CAH certification, if the amount described in paragraph (F)(1)(a) of this rule is equal to zero, the hospital shall be included in the RH payment pool described in paragraph (F)(2)(a) of this rule.

(2) Hospitals meeting the definition described in paragraph (A)(26) of this rule but do not meet the definition described in paragraph (A)(27) of this rule, shall receive funds from the rural hospital RH payment pool.

(a) For each hospital with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule, sum the hospital's total payments allocated in paragraphs (E)(1)(b), (E)(2)(d), and (E)(3)(e) of this rule.

(b) For each hospital with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule subtract the amount calculated in paragraph (F)(2)(a) of this rule, from the amount calculated in paragraph (A)(28) of this rule. If this difference for the hospital is negative, then for the purpose of this calculation set the difference equal to zero.

(c) For all hospitals with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule, sum the amounts calculated in paragraph (F)(2)(b) of this rule.

(d) For each hospital with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule, determine the ratio of the amounts in paragraphs (F)(2)(b) and (F)(2)(c) of this rule.

(e) Subtract the amount calculated in paragraph (F)(1)(c) of this rule from the amount allocated in paragraph (D)(2)(d) of this rule.

(f) For each hospital with RH classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule, multiply the ratio calculated in paragraph (F)(2)(d) of this rule, by the amount calculated in paragraph (F)(2)(e) of this rule, to determine each hospital's rural hospital payment pool amount.

(g) For each hospital, sum the amount calculated in paragraph (F)(1)(b) of this rule, and the amount calculated in paragraph (F)(2)(f) of this rule. This amount is the hospital's rural and critical access payment amount.

(G) Distribution of funds through the county redistribution of closed hospitals payment pools.

If funds are available in accordance with paragraph (C) of this rule, the funds are distributed among the hospitals according to the county redistribution of closed hospitals payment pools described in paragraphs (G)(1) to (G)(3) of this rule.

(1) If a hospital facility that is identifiable to a unique medicaid provider number closes during the current program year, the payments that would have been made to that hospital under paragraphs (E), (F), (H), and (I) of this rule for the portion of the year it was closed, less any amounts that would have been paid by the closed hospital under provisions of rules 5160-2-08 and 5160-2-08.1 of the Administrative Code for the portion of the year it was closed, shall be distributed to the remaining hospitals in the county where the closed hospital is located. If another hospital does not exist in such a county, the funds shall be distributed to hospitals in bordering counties within the state.

For each hospital identifiable to a unique medicaid provider number that closed during the immediate prior program year, the payments that would have been made to that hospital under paragraphs (E), (F), (H), and (I) of this rule, less any amounts that would have been paid by the closed hospital under provisions of rules 5160-2-08 and 5160-2-08.1 of the Administrative Code, shall be distributed to the remaining hospitals in the county where the closed hospital was located. If another hospital does not exist in such a county, the funds shall be distributed to hospitals in bordering counties within the state.

If the closed hospital's payments under paragraphs (E), (F), (H), and (I), of this rule does not result in a net gain, nothing shall be redistributed under paragraphs (G)(2) and (G)(3) of this rule.

(2) Redistribution of closed hospital funds within the county of closure.

(a) For each hospital within a county with a closed hospital as described in paragraph (G)(1) of this rule, sum the amount calculated in paragraph (E)(3)(a) of this rule, if the sum of a hospital's total payments calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1), and (F)(2) of this rule does not exceed the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule.

(b) For all hospitals within a county with a closed hospital, sum the amounts calculated in paragraph (G)(2)(a) of this rule.

(c) For each hospital within a county with a closed hospital, determine the ratio of the amounts in paragraphs (G)(2)(a) and (G)(2)(b) of this rule.

(d) For each hospital within a county with a closed hospital, multiply the ratio calculated in paragraph (G)(2)(c) of this rule, by the amount calculated in paragraph (G)(1) of this rule, to determine each hospital's county redistribution of closed hospitals payment amount, subject to the following limitation:

If the sum of a hospital's payment amounts calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1), and (F)(2) of this rule is less than the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule, then the hospital's redistribution of closed hospital funds amount is equal to the amount in paragraph (G)(2)(d) of this rule, not to exceed the amount defined in paragraph (A)(28) of this rule.

(3) Redistribution of closed hospital funds to hospitals in a bordering county.

(a) For each hospital within a county that borders a county with a closed hospital where another hospital does not exist, as described in paragraph (G)(1) of this rule, sum the amount calculated in paragraph (E)(3)(a) of this rule, if the sum of a hospital's total payments calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1) and (F)(2) of this rule does not exceed the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule.

(b) For all hospitals within counties that border a county with a closed hospital where another hospital does not exist, sum the amounts calculated in paragraph (G)(3)(a) of this rule.

(c) For each hospital within a county that borders a county with a closed hospital where another hospital does not exist, determine the ratio of the amounts in paragraphs (G)(3)(a) and (G)(3)(b) of this rule.

(d) For each hospital within a county that borders a county with a closed hospital where another hospital does not exist, multiply the ratio calculated in paragraph (G)(3)(c) of this rule, by the amount calculated in paragraph (G)(1) of this rule, to determine each hospital's county redistribution of closed hospitals payment amount subject to the following limitation:

If the sum of a hospital's payment amounts calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1), and (F)(2) of this rule is less than the hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule, the hospital's redistribution of closed hospital funds amount is the amount defined in paragraph (G)(3)(d) of this rule, not to exceed the amount defined in paragraph (A)(28) of this rule.

(H) Distribution of funds through the children's hospital pool.

(1) For each hospital meeting the children's hospital definition described in paragraph (A)(29) of this rule, sum the payment amounts as calculated in paragraphs (E), (F), and (G) of this rule. This is the hospital's calculated payment amount.

(2) For each hospital meeting the children's hospital definition described in paragraph (A)(29) of this rule, with a calculated payment amount that is not greater than the disproportionate share limit, as described in paragraph (A)(28) of this rule, subtract the amount in paragraph (H)(1) of this rule from the disproportionate share limit, as described in paragraph (A)(28) of this rule.

(3) For hospitals meeting the children's hospital definition described in paragraph (A)(29) of this rule, with calculated payment amounts that are not greater than the disproportionate share limit, as described in paragraph (A)(28) of this rule, sum the amounts calculated in paragraph (H)(2) of this rule.

(4) For each hospital meeting the children's hospital definition described in paragraph (A)(29) of this rule, with a calculated payment amount that is not greater than the disproportionate share limit, as described in paragraph (A)(28) of this rule, determine the ratio of the amounts in paragraphs (H)(2) and (H)(3) of this rule.

(5) For each hospital meeting the children's hospital definition described in paragraph (A)(29) of this rule, with a calculated payment that is not greater than the disproportionate share limit, as described in paragraph (A)(28) of this rule, multiply the ratio calculated in paragraph (H)(4) of this rule by the amount allocated in paragraph (D)(2)(e) of this rule. This amount is the children's hospital payment pool payment amount, subject to the following limitation.

If the sum of the hospital's payment amounts calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1), (F)(2), and (G) of this rule is less than the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule, then the hospital's children's hospital pool payment amount is equal to the amount calculated in paragraph (H)(5) of this rule, not to exceed the amount defined in paragraph (A)(28) of this rule.

If any hospital is limited as described in paragraph (H)(5) of this rule, calculate each hospital's limited payment by subtracting the amount defined in paragraph (A)(28) of this rule from the amount determined in paragraph (H)(5) of this rule and sum these amounts for all limited hospital(s). Subtract the sum of the limited payments from the amount in paragraph (D)(2)(e) of this rule and repeat the distribution described in paragraph (H) of this rule until all funds for this pool are expended.

(I) Distribution model adjustments and limitations through the statewide residual pool.

(1) For each hospital, sum the payment amounts as calculated in paragraphs (E), (F), (G), and (H), of this rule. This is the hospital's calculated payment amount.

(2) For each hospital, calculate the hospital's specific disproportionate share limit as defined in paragraph (A)(28) of this rule.

(3) For each hospital, subtract the hospital's disproportionate share limit as calculated in paragraph (I)(2) of this rule from the payment amount as calculated in paragraph (I)(1) of this rule to determine if a hospital's calculated payment amount is greater than its disproportionate share limit. If the hospital's calculated payment amount as calculated in paragraph (I)(1) of this rule is greater than the hospital's disproportionate share limit calculated in paragraph (I)(2) of this rule, then the difference is the hospital's residual payment funds.

(4) If a hospital's calculated payment amount, as calculated in paragraph (I)(1) of this rule, is greater than its disproportionate share limit defined in paragraph (I)(2) of this rule, then the hospital's payment is equal to the hospital's disproportionate share limit.

(a) The hospital's residual payment funds as calculated in paragraph (I)(3) of this rule is subtracted from the hospital's calculated payment amount as calculated in paragraph (I)(1) of this rule and is applied to and distributed as the statewide residual payment pool as described in paragraph (I)(5) of this rule.

(b) The total amount distributed through the statewide residual pool will be the sum of the hospital care assurance fund described in paragraph (K)(4) minus the sum of the lessor of each hospital's calculated payment amount calculated in paragraph (I)(1) of this rule or the hospital's disproportionate share limit calculated in paragraph (I)(2) of this rule.

(5) Redistribution of residual payment funds in the statewide residual payment pool.

(a) For each hospital with a calculated payment amount that is not greater than the disproportionate share limit, as described in paragraph (I)(4) of this rule, subtract the amount in paragraph (I)(1) of this rule from the amount in paragraph (I)(2) of this rule.

(b) For hospitals with calculated payment amounts that are not greater than the disproportionate share limit, sum the amounts calculated in paragraph (I)(5)(a) of this rule.

(c) For each hospital with a calculated payment amount that is not greater than the disproportionate share limit, determine the ratio of the amounts in paragraphs (I)(5)(a) and (I)(5)(b) of this rule.

(d) For each hospital with a calculated payment amount that is not greater than the disproportionate share limit, multiply the ratio calculated in paragraph (I)(5)(c) of this rule by the total amount distributed through the statewide residual pool described in paragraph (I)(4)(b) of this rule. This amount is the hospital's statewide residual payment pool payment amount subject to the following limitation:

If the sum of the hospital's payment amounts calculated in paragraphs (E), (F), (G), and (H) of this rule is less than the amount of the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule, then hospital's residual pool payment amount is equal to the amount defined in paragraph (I)(5)(d) of this rule, not to exceed the amount defined in paragraph (A)(28) of this rule.

(J) Disproportionate share adjustment.

(1) Determination of disproportionate share qualification.

(a) For each hospital, calculate the medicaid utilization rate as defined in paragraph (A)(20) of this rule.

(b) Each hospital with a medicaid utilization rate greater than or equal to one per cent and meets the obstetric services requirements as defined in paragraph (A)(33) of this rule qualifies as a disproportionate share hospital for the purposes of this rule.

(c) Each hospital with a medicaid utilization rate less than one per cent or does not meet the obstetric services requirements as defined in paragraph (A)(33) of this rule qualifies as a nondisproportionate share hospital for the purposes of this rule.

(2) Limitations on disproportionate share and indigent care payments made to hospitals.

(a) For each hospital, calculate medicaid fee for service (FFS) shortfall by subtracting from total medicaid FFS costs, as defined in paragraph (A)(1) of this rule, total medicaid FFS payments, as described in paragraph (A)(18) of this rule.

(b) For each hospital, calculate medicaid MCP shortfall by subtracting from total medicaid MCP costs, as defined in paragraph (A)(21) of this rule, the total medicaid MCP payments, as described in paragraph (A)(24) of this rule.

(c) For each hospital, calculate the total medicaid shortfall by adding the medicaid FFS shortfall as defined in paragraph (J)(2)(a) of this rule to the medicaid MCP shortfall as defined in paragraph (J)(2)(b) of this rule.

(d) For each hospital, determine the total cost of uncompensated care for people without insurance by taking the sum of the amounts described in paragraphs (A)(5) and (A)(12) of this rule.

(e) For each hospital, determine the amount received under section 1011 - federal reimbursement of emergency health services furnished to undocumented aliens from the ODM 02930, schedule E, line 7b.

(f) For each hospital, calculate the hospital disproportionate share limit by adding the total medicaid shortfall as described in paragraph (J)(2)(c) of this rule and total uncompensated care costs for people without insurance as described in paragraph (J)(2)(d) of this rule and subtracting section 1011 payments as described in paragraph (J)(2)(e) of this rule.

(g) The hospital will receive the lesser of the disproportionate share limit as described in paragraph (J)(2)(f) of this rule or the sum of disproportionate share and indigent care payments as calculated in paragraphs (E) to (I) of this rule.

(K) Payments and adjustments.

(1) Every hospital that must make payments of assessments and/or intergovernmental transfers to the department of medicaid under the provisions of rule 5160-2-08.1 of the Administrative Code shall make the payments in accordance with the payment schedule as described in this rule. If the final determination that the hospital must make payments was made by the department, the hospitals shall meet the payment schedule developed by the department after consultation with the hospitals or a designated representative thereof.

If the final determination that the hospital must make payments was made by the court of common pleas of Franklin county, the hospital shall meet the payment schedule developed by the department after consultation with the hospital or a designated representative thereof. Delayed payment schedules for hospitals that are unable to make timely payments under this paragraph due to financial difficulties will be developed by the department.

The delayed payments shall include interest at the rate of ten per cent per year on the amount payable from the date the payment would have been due had the delay not been granted until the date of payment.

(2) Except for the provisions of paragraphs (E) and (F) of rule 5160-2-08.1 of the Administrative Code, all payments of assessments and intergovernmental transfers, when applicable, from hospitals under rule 5160-2-08 of the Administrative Code shall be deposited to the credit of the hospital care assurance program fund. All investment earnings of the fund shall be credited to the fund. The department shall maintain records that show the amount of money in the fund at any time that has been paid by each hospital and the amount of any investment earnings on that amount. All moneys credited to the hospital care assurance program fund shall be used solely to make payments to hospitals under the provisions of this rule.

(3) All federal matching funds received as a result of hospital payments of assessments and intergovernmental transfers the department makes to hospitals under paragraph (K)(4) of this rule shall be credited to the hospital care assurance match fund. All investment earnings of the fund shall be credited to the fund. All money credited to the hospital care assurance match fund shall be used solely to make payments to hospitals under the provisions of this rule.

(4) The department shall make payments to each medicaid participating hospital meeting the definition of hospital as described under section 5168.01 of the Revised Code. The payments shall be based on amounts that reflect the sum of amounts in the hospital care assurance program fund described in paragraph (K)(2) of this rule and the hospital care assurance match fund described in paragraph (K)(3) of this rule. Payments to each hospital shall be calculated as described in paragraphs (E), (F), (G), (H), and (I) of this rule. For purposes of this paragraph, the value of the hospital care assurance match fund is calculated as:

Sum of hospital care assurance program fund/{1-(federal medical assistance percentage/100)}

The payments shall be made solely from the hospital care assurance program fund and the hospital care assurance match fund. If amounts in the funds are insufficient to make the total amount of payments for which hospitals are eligible, the department shall reduce the amount of each payment by the percentage by which the amounts are insufficient. Any amounts not paid at the time they were due shall be paid to hospitals as soon as moneys are available in the funds.

(5) All payments to hospitals under the provisions of this rule are conditional on:

(a) Expiration of the time for appeals under the provisions of rule 5160-2-08.1 of the Administrative Code without the filing of an appeal, or on court determinations, in the event of appeals, that the hospital is entitled to the payments;

(b) The availability of sufficient moneys in the hospital care assurance program fund and the hospital care assurance match fund to make payments after the final determination of any appeals;

(c) The hospital's compliance with the provisions of rule 5160-2-07.17 of the Administrative Code; and

(d) The payment made to hospitals does not exceed the hospital's disproportionate share limit as calculated in paragraph (J)(2) of this rule.

(6) If an audit conducted by the department of the amounts of payments made and received by hospitals under the provisions of this rule identifies amounts that, due to errors by the department, a hospital should not have been required to pay but did pay, should have been required to pay but did not pay, should not have received but did receive, or should have received but did not receive, the department shall:

(a) Make payments to any hospital that the audit reveals paid amounts it should not have been required to pay but did pay or did not receive amounts it should have received; and

(b) Take action to recover from a hospital any amounts that the audit reveals it should have been required to pay but did not pay or that it should not have received but did receive.

(7) Payments made under paragraph (K)(6)(a) of this rule shall be made from the hospital care assurance program fund. Amounts recovered under paragraph (K)(6)(b) of this rule shall be deposited to the credit of the hospital care assurance program fund. Any hospital may appeal the amount the hospital is to be paid under paragraph (K)(6)(a) of this rule or the amount to be recovered from the hospital under paragraph (K)(6)(b) of this rule to the court of common pleas of Franklin county.

(L) Confidentiality.

Except as specifically required by the provisions of this rule and rule 5160-2-24 of the Administrative Code, information filed shall not include any patient-identifying material. Information including patient-identifying information is not a public record under section 149.43 of the Revised Code and no patient-identifying material shall be released publicly by the department of medicaid or by any person under contract with the department who has access to such information.

(M) Penalties for failure to report or make payment.

(1) Any hospital that fails to report the information required under this rule and under paragraph (A) of rule 5160-2-23 of the Administrative Code on or before the dates specified in this rule and in rule 5160-2-23 of the Administrative Code shall be fined one thousand dollars for each day after the due date that the information is not reported.

(2) In addition to any other remedy available to the department under law to collect unpaid assessments and transfers, any hospital that fails to make payments of the assessments and intergovernmental transfers to the department of medicaid on or before the dates specified in this rule or under any schedule for delayed payments established under paragraph (K)(1) of this rule shall be fined one thousand dollars for each day after the due date.

(3) The director of medicaid shall waive the penalties provided for in paragraphs (M)(1) and (M)(2) of this rule for good cause shown by the hospital.

(N) Payment schedule.

The assessments, intergovernmental transfers and payments made under the provisions of this rule will be made in installments.

(1) On or before the fourteenth day after the department mails the final determination as described in rule 5160-2-08.1 of the Administrative Code, the hospital must submit its first assessment to the department.

All subsequent assessments and intergovernmental transfers, when applicable, must be made on or before the fifth working day after the date on the warrant or electronic funds transfer (EFT) issued as payment by the department as described in paragraph (N)(2) of this rule.

Each hospital shall submit its assessment amount to the Ohio department of medicaid via EFT.

(2) On or before the tenth working day after the department's deadline for receiving assessments and intergovernmental transfers, the department must make a payment to each hospital. However, the department shall make no payment to any hospital that has not paid assessments or made intergovernmental transfers that are due until the assessments and transfers are paid in full or a final determination regarding amounts to be paid is made under any request for reconsideration or appeal.

(3) If a hospital closes after the date of the public hearing held in accordance with rule 5160-2-08.1 of the Administrative Code, and before the last payment is made, as described in this paragraph, the payments to the remaining hospitals will be adjusted in accordance with paragraphs (E) to (K)(7) of this rule.

Supplemental Information

Authorized By: 5168.02
Amplifies: 5168.01, 5168.02, 5168.03, 5168.04, 5168.05, 5168.06, 5168.07, 5168.08, 5168.09, 5168.10, 5168.11, 5168.13, 5168.99, and 5168.991
Five Year Review Date: 1/1/2022
Prior Effective Dates: 10/21/1996, 7/1/2004, 8/3/2008, 6/25/2015, 6/13/2016

Rule 5160-2-10 | Payment policies for disproportionate share and indigent care adjustments for psychiatric hospitals.

• Effective: January 12, 2024
• Promulgated Under: 119.03

This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B) to (D) of rule 5160-2-01 of the Administrative Code.

(A) Definitions for each psychiatric hospital.

(1) "Cash subsidies for inpatient services received directly from state and local governments" is the amount of cash subsidies each psychiatric hospital has received from state and local governments for inpatient services for the applicable state fiscal year. In accordance with paragraph (C) of this rule, each psychiatric hospital reports cash subsidies received from state and local government on "Ohio Medicaid Hospital Cost Report" ODM 02930, for the applicable state fiscal year, schedule F, section II, column 4.

(2) "Charges for charity care" is the total charges for inpatient services provided to indigent patients, which includes charges for services provided to individuals who do not possess health insurance for the service provided. Charity care does not include bad debts, contractual allowances, or uncompensated care costs rendered to patients with insurance as described in paragraph (A)(13) of this rule. Each psychiatric hospital reports charges for charity care on ODM 02930, schedule F, section II, column 3.

(3) "Inpatient days" is the sum of the number of inpatient fee for service (FFS) hospital days as reported on ODM 02930, schedule C, section I, column 4 and the number of inpatient managed care plan (MCP) hospital days as reported on ODM 02930, schedule C, section III, column 2.

(4) "Insurance revenues" are the revenues received in the same twelve months of the hospital's cost-reporting period for inpatient services provided to, billed to, and received from all sources other than medicaid or self-pay revenues as described in paragraph (A)(6) of this rule. Each psychiatric hospital reports insurance revenues on ODM 02930, schedule F, section II, column 1.

(5) "Medicaid inpatient utilization rate" is the ratio of the psychiatric hospital's number of inpatient days attributable to patients who were medicaid eligible as described in paragraph (A)(10) of this rule divided by the psychiatric hospital's total number of inpatient days as described in paragraph (A)(3) of this rule.

(6) "Self-pay revenues" are the revenues received in the same twelve months of the hospital's cost-reporting period for inpatient services provided to, billed to, and received from either the person that received inpatient services or the family of the person that received inpatient services. Each psychiatric hospital reports self-pay revenues on ODM 02930, schedule F, section II, column 2.

(7) "Total charges for inpatient services" for each psychiatric hospital, except for free-standing, state-owned psychiatric hospitals, is the sum of the amounts reported for inpatient hospital services on ODM 02930, schedule B, column 6. For free-standing, state-owned psychiatric hospitals, "total charges for inpatient services" equals "total inpatient allowable costs" as defined in paragraph (A)(9) of this rule.

(8) "Total facility inpatient revenues" is the sum of the hospital's insurance revenues as described in paragraph (A)(4) of this rule, self-pay revenues as described in paragraph (A)(6) of this rule, and total medicaid revenues as described in paragraph (A)(11) of this rule.

(9) "Total inpatient allowable costs" is the sum of the general service and capital related costs for inpatient hospital services. Each psychiatric hospital reports total inpatient allowable costs on ODM 02930 schedule B, column 7.

(10) "Total medicaid days" is the sum of the amounts that each psychiatric hospital reports on ODM 02930, schedule F, section II, columns 6 to 8.

(11) "Total medicaid revenues" are the revenues received in the same twelve months of the hospital's cost-reporting period for inpatient services provided to, billed to, and received from all sources other than insurance revenues as described in paragraph (A)(4) of this rule or self-pay revenues as described in paragraph (A)(6) of this rule. Each psychiatric hospital reports total FFS medicaid revenues on ODM 02930, schedule H, section I, column 1 and total MCP medicaid revenues on ODM 02930, schedule I, column 2.

(12) "Uncompensated care costs" is the amount calculated by subtracting the sum of the total facility inpatient revenue as described in paragraph (A)(8) of this rule and the uncompensated care costs rendered to patients with insurance as described in paragraph (A)(13) of this rule from the total inpatient allowable costs as described in paragraph (A)(9) of this rule. For hospitals with negative uncompensated care costs, the result is equal to zero.

(13) "Uncompensated care costs rendered to patients with insurance" is the costs for an individual that has insurance coverage for the service provided, but the full cost of the service was not reimbursed because of per diem caps or coverage limitations. Each psychiatric hospital reports uncompensated care costs rendered to patients with insurance on ODM 02930, schedule F, section II, column 5.

(B) Applicability.

The requirements of this rule are limited pursuant to section 1923 of the Social Security Act, 42 USC 1396r-4 (effective October, 11, 2020).

(C) Source data for calculations.

The calculations described in this rule will be based on cost-reporting data described in paragraph (B)(1) of rule 5160-2-08 of the Administrative Code.

(D) Determination of disproportionate share qualifications for psychiatric hospitals.

Psychiatric hospitals will be determined to be disproportionate share if based on data described in paragraph (C) of this rule, they meet the obstetric services requirements as described in paragraph (A)(33) of rule 5160-2-09 of the Administrative Code, and they meet both qualifications described in paragraphs (D)(1) and (D)(2) of this rule.

(1) The hospital's medicaid inpatient utilization rate, as described in paragraph (A)(5) of this rule, is greater than or equal to one per cent; and

(2) The hospital's uncompensated care costs, as described in paragraph (A)(12) of this rule is at least sixty per cent of the hospital's total inpatient allowable costs as described in paragraph (A)(9) of this rule.

(E) Distribution of funds.

The funds available to each psychiatric hospital qualifying as a disproportionate share hospital as described in paragraph (D) of this rule are distributed among the hospitals based on data described in paragraph (C) of this rule and according to the payment formulas as follows:

(1) For each hospital, calculate the uncompensated care costs as described in paragraph (A)(12) of this rule;

(2) For all hospitals, sum all hospitals' uncompensated care costs as described in paragraph (A)(12) of this rule;

(3) For each hospital, calculate the ratio of the amount described in paragraph (E)(1) of this rule to the amount described in paragraph (E)(2) of this rule;

(4) Multiply the ratio for each hospital calculated in paragraph (E)(3) of this rule by the disproportionate share funds available to psychiatric hospitals as described in paragraph (G) of this rule to determine each hospital's disproportionate share payment amount.

(5) Each hospital will be distributed a payment amount based on the lesser of;

(a) Uncompensated care costs as determined in paragraph (A)(12) of this rule; or

(b) The hospital's disproportionate share payment as determined in paragraph (E)(4) of this rule.

(F) Payments.

The department will make payments in accordance with paragraph (E) of this rule to qualifying hospitals in accordance with paragraph (D) of this rule.

(G) Disproportionate share funds.

The maximum amount of disproportionate share funds available for distribution to psychiatric hospitals will be determined by subtracting the funds distributed in accordance with rule 5160-2-09 of the Administrative Code from the state's disproportionate share limit payment allotment determined by the centers for medicare and medicaid services (CMS) for that program year.

Last updated January 12, 2024 at 7:49 AM

Supplemental Information

Authorized By: 5164.02, 5168.02
Amplifies: 5162.03, 5164.02, 5164.70, 5168.01, 5168.02, 5168.13
Five Year Review Date: 6/1/2026
Prior Effective Dates: 9/25/1996 (Emer.), 9/10/1998, 9/15/2006, 6/25/2015

Rule 5160-2-12 | Appeals and reconsideration of departmental determinations regarding hospital inpatient and outpatient services.

• Effective: June 12, 2022
• Promulgated Under: 119.03

(A) Appeals.

Pursuant to Chapter 5160-70 of the Administrative Code, final settlements that are based upon final audits by the department may be appealed by hospitals under Chapter 119. of the Revised Code. Rule 5160-2-24 of the Administrative Code describes final fiscal audits and final settlements performed by the department. Rules 5160-1-27 and 5160-1-29 of the Administrative Code describe the audits performed by the department which may be appealable under Chapter 119. of the Revised Code. Since the scope and substance of these two types of audits differ, in no instance will the conduct and implementation of one type of audit preclude the conduct and implementation of the other.

(B) Utilization review reconsideration.

Pursuant to rule 5160-2-13 of the Administrative Code, the department or a medical review entity under contract with the department may make determinations regarding utilization review. These determinations are subject to the reconsideration process described in rule 5160-70-02 of the Administrative Code as follows:

(1) A written request for a reconsideration should be submitted to the department or the medical review entity, whichever made the initial determination as indicated by the denial letter, within sixty calendar days of the date of the determination. The department or the medical review entity has thirty business days from receipt of the request for reconsideration to issue a final and binding decision accepting, modifying, or rejecting its previous determination. The request for reconsideration must include:

(a) A copy of the written determination;

(b) A copy of the patient's medical record (if not already submitted to the review entity); and

(c) Copies of any and all additional information that may support the provider's position.

(2) If the submitted request for a reconsideration is incomplete, the department or the medical review entity will notify the provider of missing documentation. The notice will give the provider two business days to submit the missing documentation.

(3) The department will conduct an administrative review of the reconsideration decision if the provider submits its request within thirty calendar days of that decision. The department has thirty business days from receipt of the request for review to issue a final and binding decision. A request for an administrative review must include:

(a) A letter requesting a review of the reconsideration;

(b) A statement as to why the provider believes that the reconsideration decision was in error; and

(c) Any further documentation supporting the provider's position.

(4) The department may extend time frames described in paragraphs (B)(1) and (B)(3) of this rule, where adherence to time frames causes exceptional hardships to a large number of hospitals or where adherence to time frames as described in paragraphs (B)(1) and (B)(3) of this rule causes exceptional hardship to a hospital because potential determinations constitute a large portion of that hospital's total medicaid business.

(C) Reconsideration of hospital payments.

(1) Except when the department's determination is based on a finding made by medicare, the proper application of rules 5160-2-65, 5160-2-75 and 5160-2-76 of the Administrative Code and the proper calculation of amounts (including source data used to calculate the amounts) determined in accordance with rules 5160-2-66 and 5160-2-67 of the Administrative Code are subject to the reconsideration process described in rule 5160-70-02 of the Administrative Code as follows:

(a) Requests for reconsideration authorized by paragraph (C)(1) of this rule should be submitted to the department in writing. If the request for reconsideration involves a rate component or determination made at the beginning of the rate year, the request should be submitted within ninety calendar days of the beginning of the rate year. If the request involves an adjustment or a determination made by the department after the beginning of the rate year, the request should be submitted within thirty calendar days of the date the adjustment or determination was implemented. The request should include a statement as to why the provider believes that the rate component or determination was incorrect as well as all documentation supporting the provider's position.

(b) The department has thirty business days from receipt of the request for reconsideration to issue a final and binding decision.

(2) When a medicare audit finding was used by the department in establishing a rate component and the finding is subsequently overturned on appeal, the provider may request reconsideration of the affected rate component. Such requests should be submitted to the department in writing prior to final settlement as described in rule 5160-2-24 of the Administrative Code and within thirty calendar days of the date the hospital receives notification from medicare of the appeal decision. The request for reconsideration of a medicare audit finding that has been overturned on appeal should include all documentation that explain the appeal decision. The department has thirty business days in which to notify the provider of its final and binding decision regarding the medicare audit finding.

(D) State hearings for medicaid recipients whose claim for hospital services is denied.

Any recipient whose claim for hospital services is denied may request a state hearing in accordance with division 5101:6 of the Administrative Code. The determination of whether outlier payments will be made or the amounts of outlier payments as described in rule 5160-2-65 of the Administrative Code is not a denial of a claim for inpatient hospital services. Similarly, the determination of amounts payable for inpatient hospital services involving readmissions or transfers is not a denial of a claim for inpatient hospital services.

(E) The following items are not subject to the department's reconsideration process:

(1) The use of the diagnosis related groups (DRG) classification system and the method of classification of discharges within DRGs.

(2) The assignment of DRGs and severity of illness (SOI).

(3) The assignment of relative weights to DRGs based on the methodology set forth in rule 5160-2-65 of the Administrative Code.

(4) The establishment of peer groups as set forth in rule 5160-2-65 of the Administrative Code.

(5) The methodology used to determine prospective payment rates as described in rule 5160-2-65 of the Administrative Code.

(6) The methodology used to identify cost thresholds for services that may qualify for outlier payments as described in rule 5160-2-65 of the Administrative Code.

(7) The formulas used to determine rates of payment for outliers, certain transfers and readmissions, and services subject to pre-certification, as described, respectively, in rules 5160-2-65 and 5160-2-40 of the Administrative Code.

(8) The peer group average cost per discharge for all hospitals except when the conditions detailed in rule 5160-2-65 of the Administrative Code are met.

(9) Statewide calculations of the direct and indirect medical education threshold for allowable costs per intern and resident as described in rule 5160-2-67 of the Administrative Code.

(10) The threshold for establishing which hospitals will be recognized as providing a disproportionate share of indigent care as described in rule 5160-2-09 of the Administrative Code.

(11) The use of the Enhanced Ambulatory Patient Groups (EAPG) classification system and the method of classification of claim details within EAPGs.

(12) The assignment of EAPGs.

(13) The assignment of relative weights to EAPGs based on the methodology set forth in rule 5160-2-75 of the Administrative Code.

(14) The establishment of peer groups as set forth in rule 5160-2-75 of the Administrative Code.

(15) The methodology used to determine prospective payment rates as described in rule 5160-2-75 of the Administrative Code.

(16) The peer group average cost per detail for all hospitals except when the conditions detailed in rule 5160-2-75 of the Administrative Code are met.

(17) Technical denials, which are the result of failure to submit medical records within thirty calendar days of the original request in accordance with rule 5160-2-13 and 5160-1-17.2 of the Administrative Code.

Last updated June 13, 2022 at 12:25 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 6/12/2027
Prior Effective Dates: 7/1/1985, 7/3/1986, 10/19/1987, 7/1/1992, 8/1/2002

Rule 5160-2-13 | Utilization review.

• Effective: June 12, 2022
• Promulgated Under: 119.03

(A) The Ohio department of medicaid (ODM) will perform or contract with a medical review entity to perform utilization review for medicaid inpatient services regardless of the payment methodology used for reimbursement of those services. For the purposes of this rule, "ODM" means ODM or its contracted medical review entity. During the course of its analyses, ODM may request information or records from the hospital and may conduct on-site medical record reviews.

(B) ODM will review a statistical sample of all admissions retrospectively.

(1) While the nature of the review will vary depending on the category of admission, all admissions selected will be reviewed to determine whether care was medically necessary on an inpatient hospital basis; to determine if the care was medically necessary as defined in rule 5160-1-01 of the Administrative Code; to determine whether the discharge occurred at a medically appropriate time; to assess the quality of care rendered as mandated in 42 C.F.R. 456.3(b), in effect as of October 1, 2021; and to assess compliance with agency 5160 of the Administrative Code.

(2) If any of the cases reviewed for a hospital do not meet the conditions described in paragraph (B)(1) of this rule, then ODM may deny payment or recoup payment beginning with the first inappropriate admission or discharge. Any negative determinations should be made by a physician.

(3) If the diagnostic or procedural information on the claim is found to be inconsistent with that found in the medical records in conjunction with the physician attestation, then changes may be made in the coding and payment may be adjusted as described in paragraph (D)(3) of this rule.

(4) ODM may determine upon retrospective review, in accordance with this rule, that the location of services was not medically necessary, but that the services rendered were medically necessary. In such instances:

(a) The hospital may bill the department on an outpatient basis for those medically necessary services that were rendered on the date of admission in accordance with rule 5160-2-75 of the Administrative Code.

(b) Only laboratory and diagnostic radiology services rendered during the remainder of the medically unnecessary admission may be billed in accordance with rule 5160-2-75 of the Administrative Code.

(c) The outpatient bill will be submitted with a copy of the reconsideration affirming the original decision or the administrative decision issued in accordance with rule 5160-2-12 of the Administrative Code.

(d) The outpatient bill with attachments will be submitted to the department within sixty calendar days from the date on the remittance advice recouping the DRG payment for the medically unnecessary admission.

(C) ODM may include in its retrospective review sample the categories of admissions described in paragraphs (C)(1) to (D)(3) of this rule.

(1) ODM may review transfers as defined in rule 5160-2-02 of the Administrative Code. The purpose of the transfer review will be to examine the documented reasons for and appropriateness of the transfer. ODM considers a transfer appropriate if the transfer is necessary because the individual needs some treatment or care that is unavailable at the transferring hospital or if there are other exceptional circumstances that justify transfer.

Cases will be individually considered by ODM based on the merits of each case. If any of the hospital's transfer cases reviewed are found to be inappropriate transfers, then ODM may intensify the review, including the addition of prepayment review and pretransfer certification. ODM may deny payment to or recoup payment from a provider who has transferred patients inappropriately.

(2) ODM may review readmissions to determine if the readmission as defined in rule 5160-2-02 of the Administrative Code is appropriate.

(a) If the readmission is related to the first hospitalization, ODM will determine if the readmission resulted from complications or other circumstances that arose because of an early discharge or other treatment errors.

(b) If the readmission is unrelated, ODM will determine if the treatment or care provided during the readmission should have been provided during the first hospitalization.

(c) If it is determined the readmission was the result of circumstances as described in paragraph (2)(a) or (2)(b) of this rule, then any payment made for the separate admissions will be recouped. A new payment amount will be determined by collapsing any affected admissions into one payment.

(3) ODM may review claims for which outlier payments are made to determine if days or services were covered and were medically necessary. For outliers, review will be made to determine that all services were medically necessary, appropriately billed based on services rendered, ordered by a practitioner of physician services and not duplicatively billed. If it is determined that services were inappropriately billed or if days or services are determined to be noncovered or not medically necessary as described in rules 5160-1-01 and 5160-2-03 of the Administrative Code, recoupment of any overpayments will occur. Overpayments will be determined by calculating the difference between the amount paid and the amount that would be paid if the nonallowable or noncovered days or services were excluded from the claim.

(4) ODM may review admissions with short lengths of stay. Reviews in this category will be concentrated on any admission with a length of stay greater than two standard deviations below the mean length of stay for the DRG (diagnosis related groups) of that admission. This is based on the distribution, by DRG, of lengths of stay of admissions in Ohio medicaid inpatient claims. Reviews will be conducted to determine if the inpatient stay was medically necessary to provide services or if the services rendered could have been provided in an outpatient setting using observation codes as described in rule 5160-2-75 of the Administrative Code.

(5) ODM may review cases in which a denial letter has been issued by the hospital. In addition, ODM will review all cases in which the the attending practitioner of physician services or recipient (or family member) disagrees with the hospital's decision and requests a review of the case. The hospital will send a copy of each denial letter to ODM's medical review entity.

(D) ODM may review medical records to validate DRG assignment for any admission.

(1) The physician attestation process is to be completed for the medicaid program by following the medicare procedure for attestation as delineated in 42 C.F.R. 412.46, in effect as of October 1, 2021.

(2) DRG validation will be done on the basis of a review of medical records by verifying that the diagnostic and procedural coding used by the hospital is substantiated in these records.

(3) If the diagnostic and procedural information on the claim form is found to be inconsistent with that found in the medical records in conjunction with the physician attestation, the provider will submit a corrected claim reflecting this information.

(E) Pre-certification review as detailed in rule 5160-2-40 of the Administrative Code will be conducted in addition to the utilization review activities described in this rule.

(F) Outpatient hospital services may also be reviewed by ODM to determine whether the care or services were medically necessary as defined in rule 5160-1-01 of the Administrative Code, to determine whether the services were appropriately billed, and to assess the quality of care rendered as mandated in 42 C.F.R. 456.3(b), in effect as of October 1, 2021.

(G) Intensified reviews may result whenever ODM identifies inappropriate admission or billing practices during reviews conducted in accordance with this rule. These reviews may periodically necessitate that hospitals produce evidence of invoice costs supporting amounts billed for take-home drugs.

(H) Medical records will be maintained in accordance with 42 C.F.R. 482.24, in effect as of October 1, 2021. Records requested by ODM for review will be supplied within thirty calendar days of the request as described in rule 5160-1-17.2 of the Administrative Code. Failure to produce records within thirty days will result in withholding or recoupment of medicaid payments.

(I) With the exception of paragraph (H) of this rule, decisions made by ODM as described in this rule are appealable to ODM and are subject to the reconsideration process described in rule 5160-2-12 of the Administrative Code.

(J) Over or under payments resulting from a utilization review will be settled in accordance with section 5164.57 of the Revised Code.

(K) Recovery of payments for professional services.

Payments made in accordance with appendix DD to rule 5160-1-60 of the Administrative Code for professional services that are associated with a recouped hospital payment that is not eligible for resubmission due to the results of a utilization review, will be recovered by ODM.

Last updated June 13, 2022 at 12:26 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 6/12/2027
Prior Effective Dates: 10/1/1984, 7/3/1986, 10/19/1987, 7/1/1990, 3/16/1996, 5/1/2007

Rule 5160-2-14 | Potentially preventable readmissions.

• Effective: January 1, 2017
• Promulgated Under: 119.03

(A) General provisions.

(1) All hospitals that are subject to the all patient refined diagnosis related groups (APR-DRG) prospective payment methodology utilized by the Ohio department of medicaid as defined in rule 5160-2-65 of the Administrative Code are subject to the potentially preventable readmissions (PPR) provisions set forth in this rule.

(2) Hospitals that have twenty or more medicaid discharges in the reporting year as described in paragraph (D) of this rule are subject to a PPR rate adjustment as described in paragraph (E) of this rule.

(3) PPR hospital report cards are available on the department's website at medicaid.ohio.gov. Report cards will be updated biannually with the most current claims data as defined in this rule.

(B) Definitions.

(1) "Potentially preventable readmission (PPR)" is an inpatient readmission that meets all of the readmission criteria set forth in paragraph (C) of this rule, that follows a prior discharge from a hospital within thirty days and that is deemed clinically-related and clinically-preventable to the initial admission by the PPR software.

(2) "PPR software" is the "3M Health Information Systems" grouping software used to determine or group clinically-related and clinically-preventable inpatient hospital admissions.

(3) "Actual PPR rate" is the PPR rate computed as total clinically-related readmission chains as described in paragraph (B)(3)(a) of this rule, divided by the sum of initial admissions as described in paragraph (B)(3)(b) of this rule and only admissions as described in paragraph (B)(3)(c) of this rule.

(a) "Clinically-related readmission chain" is a series of admissions for the same patient where the underlying reason for readmission is related, as determined by the PPR software, to the care rendered during or within thirty days following a prior hospital admission. A clinically-related readmission may have resulted from improper or incomplete care during the initial admission or discharge planning process. The hospital where the initial admission occurred is responsible for the clinically-related readmission chain. Hospitalization resulting from an unpreventable or unrelated event occurring after discharge and planned readmissions are not considered clinically-related.

(b) "Initial admission" is an admission that is followed by a clinically-related readmission within the thirty day readmission period.

(c) "Only admission" is an admission where there was neither a prior initial admission nor a clinically-related readmission within the thirty day readmission period.

(4) "Expected PPR rate" is the PPR rate computed as total clinically-related readmission chains as described in paragraph (B)(3)(a) of the rule divided by the sum of initial admissions as described in paragraph (B)(3)(b) of this rule and only admissions as described in paragraph (B)(3)(c) of this rule.

The expected PPR rate is adjusted for severity of illness and risk of mortality by converting actual total clinically-related readmission chains into expected total clinically-related readmission chains by factoring in for each hospital its mix of adult and pediatric cases by DRG when compared to the statewide mix. Patients with a mental health comorbidity are also considered in the expected PPR rate when compared to the statewide mix.

(5) "Actual-to-expected ratio" is the actual PPR rate as described in paragraph (B)(3) of this rule divided by the expected PPR rate as described in paragraph (B)(4) of this rule.

(6) "Claims data" consists of fee-for-service claims and managed care claims data.

(7) "PPR rate adjustment" is a modification in the hospital's base rate as described in paragraph (E) of this rule.

(C) Readmission criteria.

(1) A readmission is a return hospitalization within thirty days of a prior discharge that meets all of the following criteria:

(a) The readmission is potentially preventable by the provision of appropriate care consistent with accepted care standards, based on the PPR software, in the prior discharge or during the post-discharge follow-up period.

(b) The readmission is for a condition or procedure that is clinically-related to the care provided during the prior discharge or resulting from inadequate discharge planning during the prior discharge.

(c) The PPR chain may contain one or more readmissions that are clinically-related to the initial admission. If the first readmission is within thirty days after the initial admission, the thirty day timeframe may begin again at the discharge of either the initial admission or the most recent readmission clinically-related to the initial admission.

(d) The readmission is to the same or to any other hospital.

(2) Readmissions, for the purposes of determining PPRs, excludes the following circumstances:

(a) The original discharge was a patient initiated discharge, was against medical advice (AMA), and the circumstances of such discharge and readmission are documented in the patient's medical record.

(b) The original discharge was for the purpose of securing treatment of a major or metastatic malignancy, major trauma, neonatal and obstetrical admission, transplant, HIV, and non-events as defined by the PPR software.

(c) Only admissions, which are defined by the PPR software and described in paragraph (B)(3)(c) of this rule. Planned readmissions are considered "only admissions" by the PPR software.

(D) Methodology to determine excess readmissions for calendar year 2017 and thereafter.

(1) Rate adjustments for calendar year 2017 for each hospital shall be based on each hospital's paid claims data for discharges that occurred on July 1, 2014 through June 30, 2015. For each calendar year thereafter, rate adjustments shall be based on each hospital's paid claims data from the state fiscal year ending the calendar year preceding the calendar year immediately preceding the effective date of the PPR rate adjustment.

(2) Excess readmission rates are calculated by dividing the hospital's actual PPR rate by the hospital's expected PPR rate.

(a) An actual-to-expected ratio as described in paragraph (B)(5) of this rule of one indicates that the hospital had readmissions within thirty days at a rate that is expected given their patient mix.

(b) An actual-to-expected ratio as described in paragraph (B)(5) of this rule of less than one indicates that the hospital had less readmissions within thirty days than is expected given their patient mix.

(c) An actual-to-expected ratio as described in paragraph (B)(5) of greater than one indicates that the hospital had more readmissions within thirty days than is expected given their patient mix.

(E) PPR rate adjustment.

(1) A hospital with excess readmissions defined as greater than one is subject to a reduction of their inpatient hospital-specific base rate equal to one per cent.

(2) The excess readmission penalty will be applied on January first of each calendar year and will remain in effect for that calendar year.

Last updated October 15, 2024 at 2:50 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 1/1/2022

Rule 5160-2-17 | Provision of basic, medically necessary hospital-level services.

• Effective: July 28, 2022
• Promulgated Under: 119.03

(A) In accordance with section 5168.14 of the Revised Code, each hospital that receives payment under the provisions of Chapter 5168. of the Revised Code, will provide, without charge to the individual, basic, medically necessary hospital-level services to the individual who is a resident of this state, is not a recipient of the medicaid program, and whose income is at or below the federal poverty line. Residence is established by a person who is living in Ohio voluntarily and who is not receiving public assistance in another state.

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

(1) "Basic, medically necessary hospital level services" are all inpatient and outpatient services covered under the medicaid program in Chapter 5160-2 of the Administrative Code with the exception of transplantation services and services associated with transplantation. These covered services are to be ordered by a practitioner of physician services and delivered at a hospital where the provider has clinical privileges, and where such services are permissible to be provided by the hospital under its certificate of authority granted under Chapters 3711., 3727., and 5119. of the Revised Code. Hospitals will be responsible for providing basic, medically necessary hospital-level services to those persons described in paragraph (C) of this rule.

(2) "Family" includes the patient, the patient's spouse (regardless of whether they live in the home), and all of the patient's children, natural or adoptive, under the age of eighteen who live in the home. If the patient is under the age of eighteen, the "family" will include the patient, the patient's natural or adoptive parent(s) (regardless of whether they live in the home), and the parent(s)' children, natural or adoptive, under the age of eighteen who live in the home. If the patient is the child of a minor parent who still resides in the home of the patient's grandparents, the "family" includes only the parent(s) and any of the parent(s)' children, natural or adoptive, who reside in the home.

(3) "Income" is defined as total salaries, wages, and cash receipts before taxes; cash receipts that reflect reasonable deductions for business expenses will be counted for both farm and non-farm self-employment.

(4) "Third-party payer" means any private or public entity or program that may be liable by law or contract to make payment to or on behalf of an individual for health care services. Third-party payer does not include a hospital.

(C) Determination of eligibility.

(1) A person is eligible for basic, medically necessary hospital-level services under the provisions of this rule if the person's individual or family income is at or below the current poverty guideline issued by the department of health and human services, as published at http://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines/ and effective on the date they were published in the Federal Register. The current poverty guideline that applies to the individual or family is calculated using either of the methods described in paragraphs (C)(2)(a) and (C)(2)(b) of this rule on the date of inpatient admission or outpatient service.

(2) If the income of a spouse or parent who does not live in the home cannot be obtained, or the absent spouse or parent does not contribute income to the family, determination of eligibility will proceed with the available income information. Income will be calculated by:

(a) Multiplying the person's or family's income by four, as applicable, for the three months preceding the date hospital services were provided;

(b) Using the person's or family's income, as applicable, for the twelve months preceding the date hospital services were provided.

(3) For outpatient hospital services, a hospital may consider an eligibility determination to be effective for ninety days from the initial service date, during which a new eligibility determination need not be completed. Eligibility for inpatient hospital services is determined separately for each admission, unless the patient is readmitted within forty-five days of discharge for the same underlying condition.

(4) A complete application for the hospital care assurance program is necessary prior to determination of eligibility. Each hospital will develop an application that, at a minimum, documents income, family size and eligibility for the medicaid program. The patient or a legal representative will need to sign the application. An unsigned application can be deemed acceptable if the patient is physically unable to sign the application or does not live in the vicinity of the hospital and is unable to return a signed application by mail. In these situations, the hospital representative should complete all questions on the application, sign the application, and document why the patient is unable to sign the application. A hospital may create policies, in accordance with paragraph (F) of this rule, that allow for the completion and signature of an application electronically provided there is reasonable assurance that it is the patient or the patient's legal representative who signs the application.

(5) A hospital system may create policies, in accordance with paragraph (F) of this rule, that allow for all hospitals in the system to use a single approved application provided that the provisions of paragraph (C)(3) of this rule are maintained.

(6) The hospital will accept application for services without charge until three years from the date of the follow-up notice, as described in paragraphs (D)(2) and (D)(3) of this rule, has elapsed.

(7) Applicants will cooperate in supplying information about health insurance or medical benefits available so a hospital may determine any potential third-party resources that may be available.

(8) Nothing in this rule will be construed to prevent a hospital from assisting or requiring an individual to apply for medicaid before the hospital processes an application under this rule.

(D) Billing of claims.

(1) Claims should be billed in accordance with section 5168.14 of the Revised Code and this rule.

(2) If the written statement as described in division (B)(2) of section 5168.14 of the Revised Code is printed on the back of the hospital's bill or data-mailer, the hospital will reference the statement on the front of the bill or data-mailer.

(E) Notices.

(1) Each hospital that receives payment under Chapter 5168. of the Revised Code will post notices in appropriate areas of their facility, including but not limited to the admissions areas, the business office, and the emergency room. The posted notices will specify the rights of persons with incomes at or below the federal poverty line to receive, without charge to the individual, basic, medically necessary hospital-level services at the hospital.

Posted notices will include all of the following in order to comply with the criteria as described in this paragraph:

(a) At a minimum, the rights of individuals to receive without charge, basic, medically necessary hospital-level services;

(b) Clear wording in simple terms understandable by the population serviced;

(c) Information printed in English and other languages that are common to the population of the area serviced;

(d) Print that is clearly readable at a distance of twenty feet or the expected vantage point of the patrons.

(2) The facility will make reasonable efforts to communicate the contents of the posted notice to persons it has reason to believe cannot read the notice.

(F) Documentation.

Each hospital will establish and maintain a written policy outlining its internal policy for administration of the hospital care assurance program in compliance with this rule and with rule 5160-2-23 of the Administrative Code. Each hospital may change its written policy as needed, but policy changes cannot be implemented retroactively. The written policy will include, but is not limited to, the following:

(1) Procedure for taking applications and a copy of the current application in use as described in paragraph (C) of this rule; and

(2) Procedure for eligibility determination including the determination of family size and determination of income. If the hospital needs verification of income other than the application, the written policy should describe what constitutes acceptable income documentation.

(G) Reporting.

(1) Information regarding the number and identity of individuals served pursuant to this rule should be reported on the ODM 02930, schedules F and J, which is submitted annually along with a certification of the accuracy of this reported data as described by rule 5160-2-23 of the Administrative Code. The ODM 02930 and instructions for completion are available on the department's website.

(2) The use of estimation methods to determine amounts for charges related to non-hospital level services or to determine the health insurance status of patient charges on patient accounts is not permitted.

(3) Each hospital will maintain, make available for review, and provide to the department or the department's disproportionate share hospital auditor on request, any records necessary to document its compliance with the provisions of this rule, including:

(a) Any documents, including medical records of the population served, from which the information to be reported on the ODM 02930 was obtained;

(b) Accounts that clearly segregate the services rendered under the provisions of this rule from other accounts; and

(c) Copies of the determinations of eligibility under paragraph (C) of this rule.

(4) Hospitals will retain these records for a period of six years from the date of receipt of payment based upon those records or until any audit initiated within the six-year period is completed.

(H) This rule in no way alters the scope or limits the obligation of any governmental entity or program, including the program awarding reparations to victims of crime under sections 2743.51 to 2743.72 of the Revised Code and the program for medically handicapped children established under section 3701.023 of the Revised Code, to pay for hospital services in accordance with state or local law.

Last updated July 28, 2022 at 9:01 AM

Supplemental Information

Authorized By: 5168.02
Amplifies: 5168.02,5168.14
Five Year Review Date: 7/28/2027
Prior Effective Dates: 5/22/1992 (Emer.), 10/1/1993 (Emer.), 12/14/2000

Rule 5160-2-22 | Non-DRG prospective payment for hospital services.

• Effective: December 5, 2019
• Promulgated Under: 119.03

This rule applies to all hospital services excluded from the inpatient hospital and outpatient hospital prospective payment systems.

(A) Applicability.

(1) Cost-related reimbursement, where payments are made for services to approximate cost based on a historical cost-to-charge ratio, and where no subsequent reconciliation occurs, applies to:

(a) All outpatient hospital services provided by hospitals excluded from outpatient prospective payment as set forth in rule 5160-2-05 of the Administrative Code.

(b) All inpatient hospital services provided by hospitals excluded from inpatient prospective payment as set forth in rule 5160-2-05 of the Administrative Code.

(B) Payments under non-DRG prospective payment.

(1) Payments for services subject to non-DRG prospective payment are made by applying a historic cost-to-charge ratio to hospital allowed charges.

(a) For outpatient services, the ratio used is medicaid outpatient costs as reported on ODM 02930, schedule H, section II divided by medicaid outpatient charges as reported on ODM 02930, schedule H, section II. For inpatient hospital services, the ratio used is medicaid inpatient costs, as reported on the ODM 02930, schedule H, section I, divided by medicaid inpatient charges as reported on the ODM 02930, schedule H, section I.

(b) For those hospitals which do not file the ODM 02930 cost-report, the ratio used is the statewide average. For outpatient services, the ratio used is the sum of medicaid outpatient costs as reported on ODM 02930, schedule H, section II for all Ohio hospitals, divided by the sum of medicaid outpatient charges as reported on ODM 02930, schedule H, section II for all Ohio hospitals. For inpatient hospitals services, the ratio used is the sum of medicaid inpatient costs as reported on the ODM 02930, schedule H, section I for all Ohio hospitals, divided by the sum of medicaid inpatient charges as reported on the ODM 02930, schedule H, section I for all Ohio hospitals.

(c) The ratio used for a claim payment will be the ratio that is operational in the claims processing system on the date the claim is paid and effective on the date of admission. The ratios which are operational during a prospective rate year in the claims processing system reflect data from each hospital's cost-report filed with the department during the calendar year proceeding the year during which the prospective rate year begins.

(2) For hospitals subject to non-DRG prospective payment, the historical cost-to-charge ratio described in paragraph (B)(1) of this rule shall be either:

(a) Ninety per cent of the calculated cost-to-charge ratio for freestanding rehabilitation hospitals and freestanding long-term acute care hospitals, as defined in rule 5160-2-05 of the Administrative Code; or

(b) Ninety-one and seven tenths per cent of the calculated cost-to-charge ratio for cancer hospitals, as defined in rule 5160-2-05 of the Administrative Code.

(C) In general, reasonable cost reimbursement recognizes costs that are reasonable and allowable under Title XVIII standards and principles described in 42 C.F.R 413.1 to 413.40 effective as of October 1, 2018, except as otherwise provided in this paragraph. These Title XVIII standards and principles are applicable to those covered inpatient and outpatient hospital services as identified in Chapter 5160-2 of the Administrative Code which are subject to cost-related reimbursement as described in this rule.

(1) The costs identified in paragraphs (C)(1)(a) to (C)(1)(f) of this rule are nonallowable.

(a) Cost of goods or services furnished free, by the hospital, or at less than fair market value. For example, the cost of office space or hospital employee time used to prepare physician invoices for physicians who invoice the department on a fee-for-service basis.

(b) Cost of services not reimbursable due to not having been billed timely as defined in rule 5160-1-19 of the Administrative Code.

(c) Cost of services which would be or are covered by a third-party payer as described in rule 5160-1-08 of the Administrative Code.

(d) The amount of any interest expense for money borrowed to alleviate cash flow problems resulting from rate reductions imposed for delinquent filing of cost reports as provided in rule 5160-2-23 of the Administrative Code.

(e) The amount of any interest on overpayments and any interest expense for money borrowed to alleviate cash flow problems resulting from an interest assessment as defined in rule 5160-1-25 of the Administrative Code.

(f) Costs which exceed limits described in 42 C.F.R. 413.30 effective as of October 1, 2018 except that the department may exempt certain facilities from these limits as described in 42 C.F.R. 413.30. The determinations to exempt facilities according to 42 C.F.R. 413.30 will be made during the final settlement process.

(2) Provisions of Title XVIII related to prospective payment for inpatient hospital services as described in 42 C.F.R. 412.1 to 412.125 effective as of October 1, 2018 are not applicable to hospital services reimbursed under the provisions of this rule. Hospital services described in this rule are reimbursed under the provisions described in paragraphs (C) to (C)(1)(f) of this rule except in instances when those regulations have been altered to accommodate the Title XVIII prospective payment system.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 12/5/2024
Prior Effective Dates: 7/3/1986

Rule 5160-2-23 | Cost reports.

• Effective: February 19, 2023
• Promulgated Under: 119.03

(A) For cost-reporting purposes, each eligible provider, as defined in rule 5160-2-01 of the Administrative Code, is to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Failure to submit all necessary items and schedules will delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (A)(7) of this rule.

Any hospital that fails to submit cost reports on or before the dates specified by the department of medicaid (ODM) will be fined one thousand dollars for each day after the due date that the information is not reported.

The hospital is to complete and submit the ODM 02930 "Ohio Medicaid Hospital Cost Report" that is applicable to the state fiscal year in which the hospital's cost reporting period ends. The hospital's cost report is to:

(1) Be prepared in accordance with medicare principles governing reasonable cost reimbursement set forth in the providers' reimbursement manual "CMS Publications, 15-1 and 15-2", as applicable to the hospital's reporting period.

(2) Include all information necessary for the proper determination of costs payable under medicaid, including financial records and statistical data.

(3) Be submitted in accordance with the cost report instructions and include an electronic copy of the medicare cost report, which is to be identical in all respects to the cost report submitted to the medicare fiscal intermediary.

(4) Include the cost report certification executed by an officer of the hospital attesting to the accuracy of the cost report and to the accuracy of the Omnibus Budget Reconciliation Act (OBRA) survey. In addition, all subsequent revisions to the cost report are to include an executed certification.

(5) The executed certification is to include an acknowledgement by the officer of the hospital that an independent, certified public accountant has successfully verified the data reported on "Schedule F" of the cost report in accordance with the procedures included in the cost report instructions. In addition, all subsequent revisions to "Schedule F" are also to be successfully verified by an independent, certified public accountant in accordance with the recertification procedures included in the cost report instructions.

(6) For hospital reporting periods ending between January first and June thirtieth the cost report is to be postmarked on or before December thirty-first of the same calendar year. For hospital reporting periods ending between July first and December thirty-first, the cost report is to be postmarked on or before June thirtieth of the following calendar year.

(a) Extensions may be granted as specified in the cost report instructions.

(b) The department may grant a blanket extension that affects one or both of the due dates described in paragraph (A)(6) of this rule. When the department grants a blanket extension, hospitals may still request an extension as specified in paragraph (A)(6)(a) of this rule.

(7) Hospitals that fail to submit cost reports timely as described in paragraph (A) of this rule will receive a delinquency letter from ODM and are subject to notification that thirty days following the date on which the cost report was due, payments for hospital services will be suspended. Suspension of payments will be terminated on the fifth working day following receipt of the delinquent cost report. At the beginning of the third month following the month in which the hospital cost report became overdue, if the cost report has not yet been submitted, termination of the provider from the program will be proposed in accordance with Chapter 5160-1 of the Administrative Code.

(8) Hospitals are to separately report all supplemental payments received for services provided during the cost report period, including;

(a) "Medicaid Managed Care Incentive Payments," as established by Section 309.30.33 of Amended Substitute House Bill 153 of the 129th General Assembly, and continued as a baseline program, and

(b) "Hospital Additional Payments," as established by Section 16 of Amended Substitute Senate Bill 310 of the 133rd General Assembly and continued in Section 333.45 of Amended Substitute House Bill 110 of the 134th General Assembly.

(B) Hospitals having a distinct part psychiatric or rehabilitation unit recognized by medicare in accordance with the provisions of 42 C.F.R. 412.25 effective as of October 1, 2022, 42 C.F.R. 412.27 effective as of October 1, 2022, and 42 C.F.R. 412.29 effective as of October 1, 2022, are to identify distinct part unit costs separately within the cost report as described in paragraph (A) of this rule.

(C) Ohio hospitals performing ambulatory surgery within the hospital outpatient setting are to identify ambulatory surgery costs and charges separately within the cost report as described in paragraph (A) of this rule.

(D) Ohio hospitals providing services to medicaid managed care entities (MCE) enrollees are to identify MCE costs, charges and payments separately within the cost report as described in paragraph (A) of this rule.

(E) It is not necessary for the hospital to wait for the medicare (Title XVIII) audit in order to file the initial cost report for the stated time period. The interim cost report filing can be audited by ODM prior to any applicable final adjustment and settlement. If an amount is due ODM as a result of the filing, payment is to be forwarded, in accordance with the cost report instructions, at the time the cost report is submitted for it to be considered a complete filing. Any revised interim cost report is to be received within thirty days of the mailing of the interim cost settlement. A desk audit will be performed by the hospital cost report review and audit section on all as filed and interim cost reports. An interim cost settlement by ODM does not preclude the finding of additional cost exceptions in a final settlement for the same cost-reporting period.

(1) If an amended medicare cost report is filed with the medicare fiscal intermediary, a copy of the amended medicare cost report is to be filed with the hospital audit section. Information contained in the amended medicare cost report will be incorporated into the interim cost report, as originally filed, if received prior to interim settlement; otherwise, it is subject to the provisions of paragraph (E) of this rule.

(2) Adjustments may be made to the interim cost report as described in rule 5160-2-24 of the Administrative Code.

(F) Out-of-state hospitals that are paid on a non-diagnostic related groups (DRG) prospective payment basis as described in rule 5160-2-22 of the Administrative Code and provide either inpatient or outpatient services, or both, to eligible Ohio medicaid recipients will be assigned a cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code.

Last updated February 21, 2023 at 8:38 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02, 5164.70
Five Year Review Date: 2/19/2028
Prior Effective Dates: 1/1/1984, 10/1/1984, 7/29/1985, 12/22/1985, 10/19/1987, 4/23/1988, 11/15/1993, 3/16/1996, 9/2/2004, 9/17/2005, 7/17/2008, 10/1/2010, 1/1/2016

Rule 5160-2-24 | Audits.

• Effective: February 19, 2023
• Promulgated Under: 119.03

(A) General provisions.

(1) Audits will be conducted by the Ohio department of medicaid for services rendered by the hospital under the medicaid program. The examination of hospital costs and charges will be made in consideration with generally accepted auditing standards necessary to fulfill the scope of the audit. To facilitate this examination, providers will make available all records and source documents necessary to fully disclose the extent of services provided to program recipients, the corresponding costs and charges made and payments received for such services, for the period corresponding to the cost-reporting period. The principle objective of the audit is to enable the department to determine that payment has been, or will be made, in accordance with federal, state, and department standards. Based on the audit, adjustments in payments to the provider will be made as necessary by provisions of this rule. Records necessary to fully disclose the extent of services provided will be maintained for a period of six years or, if an audit has been initiated, until the audit is completed and every exception is resolved. Said records will be made available, upon request, to the department for audit purposes. No payment for outstanding medical services can be made if a request for audit is refused.

(2) Additionally, audits will be performed to verify hospital costs and charges utilized in the determination of the hospital's contribution to and reimbursement from the hospital care assurance fund and disproportionate share fund as described in rules 5160-2-08, 5160-2-08.1, 5160-2-09 and 5160-2-10 of the Administrative Code.

(3) All audit activities described in this rule may be undertaken during any rate year for the purpose of assuring accuracy of data maintained by the department.

(B) Scope of audits for hospital services reimbursed on a non-diagnostic related groups (DRG) prospective payment basis.

(1) For hospital services reimbursed on a non-DRG prospective payment basis as identified in rule 5160-2-22 of the Administrative Code, audits are performed to determine whether:

(a) Services billed were provided;

(b) Services were provided to persons eligible as medicaid recipients on the date(s) services were rendered;

(c) Services billed are covered under the medicaid program in accordance with Chapter 5160-2 of the Administrative Code;

(d) Costs reported to the department represent actual incurred, reasonable, and allowable costs in accordance with the provisions of rule 5160-2-22 of the Administrative Code;

(e) Payments made to the hospital for services rendered during the cost period being audited were sufficient or insufficient in relation to audit findings;

(f) Payments made under medicaid are, in the aggregate on a statewide basis, equal to or less than amounts that would have been recognized under Title XVIII (medicare) of the Social Security Act in accordance with 42 C.F.R. 447.272 effective as of October 1, 2022 for comparable services and on a hospital-specific basis equal to or less than the provider's customary and prevailing charges for comparable services in accordance with 42 C.F.R. 447.253 effective as of October 1, 2022;

(g) Amounts of third-party payments reported to the department as described in rules 5160-1-08 and 5160-2-25 of the Administrative Code reflect the actual amounts received;

(h) For the purpose of updating interim payment rates that are subject to cost settlement, desk audit procedures will take into consideration the relationship between the prior year's reported costs and audited costs; and

(i) Amounts paid by the hospital and payments made by the department related to the indigent care adjustments described in rules 5160-2-09 and 5160-2-10 of the Administrative Code were based upon data described in rules 5160-2-09 and 5160-2-10 of the Administrative Code.

(2) Underpayments or overpayments determined as a result of findings made under the provisions of paragraphs (B)(1)(a) to (B)(1)(h) of this rule will be reconciled at the time of final settlement as described in paragraph (D)(2) of this rule taking into account any adjustments made during interim settlements as provided in rule 5160-2-23 of the Administrative Code.

(C) Scope of audits for hospital services reimbursed on a prospective payment basis.

(1) For hospitals services subject to prospective payment, audit activities are undertaken for several purposes. For each cost-reporting period, cost reports are audited, following the criteria outlined in paragraphs (C)(1)(a) to (C)(1)(e) of this rule for the purpose of reaching interim and final settlement with a hospital. For determination of amounts related to indigent care adjustment provisions described in rules 5160-2-09 and 5160-2-10 of the Administrative Code, audit steps will be performed following the criteria outlined in paragraph (C)(1)(h) of this rule. During years in which prospective payments are being rebased, additional activities such as those described in paragraphs (C)(1)(f) and (C)(1)(g) of this rule are undertaken to establish program costs used for the calculations described in rules 5160-2-65 and 5160-2-75 of the Administrative Code. For hospital services subject to prospective payment, desk or field audits of interim cost reports are performed to determine whether:

(a) Services billed were provided.

(b) Services billed were provided to persons eligible as medicaid recipients on the date(s) services were rendered.

(c) Services billed are covered under the medicaid program in accordance with Chapter 5160-2 of the Administrative Code.

(d) Payments made under medicaid are, in the aggregate on a statewide basis, equal to or less than amounts that would have been recognized under Title XVIII (medicare) of the Social Security Act in accordance with 42 C.F.R. 447.272 effective as of October 1, 2022 for comparable services and on a hospital-specific basis equal to or less than the provider's customary and prevailing charges for comparable services in accordance with 42 C.F.R. 447.253 effective as of October 1, 2022.

(e) Amounts of third-party payments reported to the department as described in rules 5160-1-08 and 5160-2-25 of the Administrative Code reflect the actual amounts received.

(f) Costs reported to the department represent actual incurred, reasonable, and allowable costs in accordance with rule 5160-2-22 of the Administrative Code.

(g) Medicaid discharges, visits, and associated charges and days as reported on the cost report are consistent with those reflected for the same period in the department's paid claims history. In cases where data submitted by the hospital on the cost report are inconsistent with data in the department's paid claims data file, the cost report is subject to adjustment as described in paragraph (D)(2) of this rule. Inconsistencies subject to adjustment include, but are not limited to:

(i) Submitted discharges and visits lower than those in the department's paid claims data file;

(ii) Submitted charge-to-day ratio lower than that in the department's paid claims data file;

(iii) Submitted charges lower than those in the department's paid claims data file; and

(iv) Other inconsistencies that necessitate analysis and auditor judgment to determine the appropriate type of adjustment.

(h) Amounts related to indigent care adjustments described in rules 5160-2-09 and 5160-2-10 of the Administrative Code were based upon data described in rules 5160-2-09 and 5160-2-10 of the Administrative Code.

(2) For hospitals subject to prospective payment for inpatient and outpatient services, the audits may result in the following adjustments:

(a) If the review identified in paragraphs (C)(1)(g)(i) to (C)(1)(g)(iv) of this rule indicates that the cost report reflects fewer medicaid discharges or visits, or a discrepancy exists between reported medicaid charges and those reflected in the department's paid claims data file, the interim cost report may be adjusted to reflect inpatient days, outpatient visits, charges, and discharge counts from the department's paid claims data file.

(b) If the reviews identified in paragraphs (C)(1)(a) to (C)(1)(c) and (C)(1)(e) of this rule indicate that inappropriate charges were attributed to medicaid program charges in the cost report, the interim cost report will be adjusted to remove such charges.

(c) If the review described in paragraph (C)(1)(f) of this rule identifies that nonallowable disallowed costs were included in the cost report, the interim cost report will be adjusted to remove such costs.

(3) Overpayments determined as a result of findings made under the provisions of paragraphs (C)(1)(a) to (C)(1)(e) of this rule will be collected by the department.

(D) Interim and final settlement.

(1) Any adjustments described in paragraph (C)(2) of this rule will be reflected in the interim or final settlement cost report. Overpayments or underpayments, as described in paragraphs (C)(1)(a) to (C)(1)(d) of this rule, will be collected by the department as settlements based upon findings associated with the cost-reporting period being settled.

(2) Final settlement constitutes the implementation of the final fiscal audit for a cost-reporting period.

(a) Any adjustments not incorporated into interim settlement will be incorporated into final settlement for that cost-reporting period.

(b) Any pending request for reconsideration filed pursuant to paragraphs (B) and (C) of rule 5160-2-12 of the Administrative Code will be incorporated into final settlement.

(c) If a hospital has an outstanding medicare appeal that has not been resolved and that could affect settlement of hospital-specific rate components, the hospital may accept, with reservations, final settlement incorporating adjustments not based on unresolved medicare audit exceptions and hold open that portion of the settlement, with all rights to appeal under Chapter 119. of the Revised Code, based on unresolved medicare audit exceptions.

(d) In no instance will adjustments to rates that were in effect during the period covered by final settlement be made following final settlement. Components of rates that are based solely on hospital-specific data are subject to recalculation and adjustment after such rates have been in effect for two prospective payment periods following the implementation of rebased rate components.

Last updated February 21, 2023 at 8:38 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 2/19/2028
Prior Effective Dates: 10/1/1984, 10/19/1987, 8/1/1988 (Emer.), 9/3/1991 (Emer.), 7/1/1992

Rule 5160-2-25 | Coordination of benefits: hospital services.

• Effective: July 9, 2023
• Promulgated Under: 119.03

Rule 5160-1-08 of the Administrative Code sets forth general provisions that the department make payment for covered services only after any available third-party benefits are exhausted. In addition, this rule identifies other provisions applicable to services provided by hospitals.

(A) All hospitals are to use third-party resources for all services a consumer receives while in the hospital. If a hospital receives reimbursement from a third-party after submitting a claim or after receiving payment from the department, the hospital is to repay the department by submitting a claim adjustment. Patient liabilities associated with persons eligible for medicaid are described in division 5160:1 of the Administrative Code and are considered a third-party resource. Benefits available through Title XVIII of the Social Security Act under medicare part A and part B, including medicare part A lifetime reserve days, or through medicare part C (medicare advantage) are considered third-party resources.

(B) The following payment provisions apply when billing for services provided to medicaid eligible consumers with available resources.

(1) For qualified medicare beneficiaries (QMB), including QMB plus and medicaid consumers enrolled in medicare part A, the following payment provisions apply to cost-sharing liability for inpatient services.

(a) For purposes of paragraph (B)(1) of this rule, the "medicaid maximum allowed amount" is the amount that would be payable by medicaid if the hospitalization were billed, in its entirety, to the department as a medicaid-only claim for a medicaid eligible consumer. The medicaid maximum allowed amount is calculated as:

(i) Described in rule 5160-2-65 of the Administrative Code in the case that a hospital is paid in accordance with the all patient refined diagnosis related groups (APR-DRG) prospective payment system; or

(ii) Described in rule 5160-2-22 of the Administrative Code in the case that a hospital is subject to non-DRG prospective payment.

(b) Except as described in paragraph (B)(3) of this rule, for persons described in paragraph (B)(1) of this rule, the department will pay as cost sharing for inpatient hospital services the lesser of:

(i) The sum of the deductible, coinsurance, and co-payment amount as provided by medicare part A; or

(ii) The medicaid maximum allowed amount, as described in paragraph (B)(1)(a) of this rule, minus the total prior payment, not to equal less than zero. The total prior payment includes the amount paid or payable by medicare and any other applicable third-party payment for services billed.

(c) If the department has a cost-sharing liability but is unable to calculate a medicaid maximum as described in paragraph (B)(1)(a) of this rule, the department may pay the sum of the deductible, coinsurance, and co-payment amount as provided by medicare part A.

(d) If a patient who is jointly eligible for medicare part A and medicaid exhausts medicare part A benefits while hospitalized, and the patient's hospitalization exceeds the applicable medicare threshold, the department will pay the difference between that amount payable by medicare and the medicaid maximum allowed amount as described in paragraph (B)(1)(a) of this rule.

(2) For QMB, including QMB plus and medicaid consumers enrolled in medicare part B, the following payment provisions apply to cost-sharing liability for hospital services covered by medicare part B:

(a) For purposes of paragraph (B)(2) of this rule, the "medicaid maximum allowed amount" is the amount that would be payable by medicaid if the hospitalization was billed, in its entirety, to the department as a medicaid-only claim for a medicaid eligible consumer. The medicaid maximum allowed amount is calculated as:

(i) Described in rule 5160-2-65 of the Administrative Code in the case that a hospital is paid in accordance with the APR-DRG prospective payment system; or

(ii) Described in rule 5160-2-75 of the Administrative Code in the case that a hospital is paid in accordance with the enhanced ambulatory patient grouping (EAPG) prospective payment system; or

(iii) Described in rule 5160-2-22 of the Administrative Code in the case that a hospital is subject to non-DRG prospective payment.

(b) Except as described in paragraph (B)(3) of this rule, for persons described in paragraph (B)(2) of this rule, the department will pay as cost sharing for hospital services covered by medicare part B the lesser of:

(i) The sum of the deductible, coinsurance, and co-payment amount as provided by medicare part B; or

(ii) The medicaid maximum allowed amount, as described in paragraph (B)(2)(a) of this rule, minus the total prior payment, not to equal less than zero. The total prior payment includes the amount paid or payable by medicare and any other applicable third-party payment for services billed.

(c) If the department has a cost-sharing liability but is unable to calculate a medicaid maximum as described in paragraph (B)(2)(a) of this rule, the department may pay the sum of the deductible, coinsurance, and co-payment amount as provided by medicare part B.

(3) For QMB and medicaid consumers enrolled in medicare part C managed health care plans (medicare advantage plans) the department pays in accordance with rule 5160-1-05.1 of the Administrative Code.

(4) For inpatient hospital services, if a consumer is entitled to hospital insurance benefits other than medicare including health insurance benefits, the department pays either the applicable APR-DRG prospective payment as described in rule 5160-2-65 of the Administrative Code or the payment applicable for services reimbursed on non-DRG prospective payment as described in rule 5160-2-22 of the Administrative Code, minus any resources available to the patient for hospital services including health insurance benefits. Such resources may include medicare part B payments including health insurance benefits. For outpatient hospital services, if a consumer is entitled to hospital insurance benefits other than medicare, the department pays either in accordance with rule 5160-2-75 of the Administrative Code for hospitals subject to EAPG prospective payment or in accordance with rule 5160-2-22 of the Administrative Code for hospitals subject to non-DRG prospective payment, minus any resources available to the patient. For both inpatient and outpatient services, if the resources available to a recipient equal or exceed amounts payable in accordance with this paragraph, the department makes no payment for the hospital services.

Last updated July 10, 2023 at 8:38 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02, 5164.70
Five Year Review Date: 7/9/2028
Prior Effective Dates: 4/1/2017

Rule 5160-2-30 | Hospital franchise fee program.

• Effective: December 15, 2019
• Promulgated Under: 119.03

This rule sets forth the assessment rate for the hospital franchise fee program implemented under sections 5168.20 to 5168.28 of the Revised Code.

(A) Definitions

For purposes of the hospital franchise fee program only, ''total facility costs'' are as defined in section 5168.20 of the Revised Code, and also exclude a hospital's costs associated with providing care to recipients of the medicare program as shown on the cost-reporting data used for purposes of determining the hospital's assessment under section 5168.21 of the Revised Code.

(B) Assessment

(1) For the program year that ends in calendar year 2020, the amount of each hospital's franchise fee assessment shall be three and one thousand nine hundred sixty-five ten-thousandths per cent of the hospital's total facility costs as defined in paragraph (A) of this rule.

(2) For the program year that ends in calendar year 2021, the amount of each hospital's franchise fee assessment shall be three and thirty-five hundredths per cent of the hospital's total facility costs as defined in paragraph (A) of this rule.

(3) For the program year that ends in calendar year 2022, and for each program year thereafter, the amount of each hospital's franchise fee assessment shall be three and thirty-seven hundredths per cent of the hospital's total facility costs as defined in paragraph (A) of this rule.

(4) The department may establish a rate higher or lower than the rates described in paragraphs (B)(1) to (B)(3) of this rule based on the franchise fee assessment needed to operate the current program year.

(C) Hospitals not enrolled as medicaid providers

(1) Hospitals, as defined in section 5168.20 of the Revised Code, that are not enrolled in the medicaid program shall, upon request, submit to the department an electronic copy of the hospital's medicare cost report (CMS 2552-10) or audited financial statements for the period described in section 5168.21 of the Revised Code.

(2) Hospitals not enrolled as medicaid providers shall be assessed a hospital franchise fee as described in paragraph (B) of this rule.

(3) Each hospital that is not enrolled as a medicaid provider shall pay the assessment according to a schedule established by the department at the time the department mails its written notice of the final determination of the hospital's assessment.

Supplemental Information

Authorized By: 5164.02, 5168.26
Amplifies: 5168.20, 5168.21, 5168.22, 5168.23, 5168.24, 5168.25, 5168.26, 5168.27,5168.28
Five Year Review Date: 12/15/2024
Prior Effective Dates: 10/14/2010 (Emer.), 5/9/2013 (Emer.)

Rule 5160-2-40 | Psychiatric pre-certification review.

• Effective: June 12, 2022
• Promulgated Under: 119.03

(A) Definitions.

For purposes of this rule, the following definitions apply:

(1) A "hospital" is a provider eligible under rule 5160-2-01 of the Administrative Code.

(2) "Medical necessity" is as defined in rule 5160-1-01 of the Administrative Code.

(3) "Pre-certification" is a process whereby the Ohio department of medicaid (ODM) or its contracted medical review entity assures that covered psychiatric services are medically necessary and are provided in the most appropriate and cost effective setting.

(4) A "psychiatric admission" is an admission of an individual to a hospital with a primary diagnosis of mental illness and not a medical or surgical admission. A discharge from a medical unit and an admission to a distinct part psychiatric unit within the same facility is considered a psychiatric admission and is subject to pre-certification.

(5) "Standards of medical practice" are nationally recognized protocols for diagnostic and therapeutic care. These protocols are approved by the medicaid program. ODM will notify providers of the standards of medical practice to be used by ODM. If ODM should change the protocols, providers will be notified sixty business days in advance.

(B) Guidelines for pre-certification.

(1) The decision that the provision of care is medically necessary will be based upon nationally recognized standards of medical practice, derived from indicators of severity of illness and intensity of services. Both severity of illness and intensity of service should be present to justify proposed care.

(2) The individual circumstances of each patient are considered when making a decision about the appropriateness of a hospital admission. Issues that will be considered in making the decision about whether or not an admission is medically necessary include psycho-social factors and factors related to the home environment including proximity to the hospital and the accessibility of alternative sites of care. These issues should be fully documented in the medical record in order to be considered as part of the review.

(3) If an inpatient stay is not deemed medically necessary, the location of service delivery may be altered as a result of pre-certification.

(C) Excluded from the pre-certification process are:

(1) Recipients enrolled in managed care organizations under contract with ODM for provision of health services to recipients;

(2) Patients who are jointly eligible for medicare and medicaid and who are being admitted under the medicare "part A" benefit; or

(3) Medical or surgical admissions.

(D) Pre-certification of psychiatric admissions.

(1) All pre-certification requests for psychiatric admissions for individuals who are medicaid eligible at the time of the admission will be submitted to ODM or its reviewing agency prior to an admission to a hospital or within two business days of the admission.

(2) The provider will request pre-certification for a psychiatric admission by submitting an electronic request to ODM. The reviewing agency is to make a decision on a pre-certification request within three business days of receipt of a properly submitted request, which is to include the information addressed in the standards of medical practice. A request is properly submitted if all information needed by the reviewing agency to make a decision based upon the guidelines set forth in paragraph (B) of this rule has been provided to the reviewing agency. All negative decisions will be reviewed by a physician representing ODM or its reviewing agency. The reviewing agency will notify the recipient, the requesting provider, the hospital, and ODM of all decisions in writing by the close of the fourth business day after the request is received.

(3) Pre-certification may be requested on a retrospective basis when:

(a) a patient is not identified as a medicaid recipient; or

(b) eligibility is pending at the time of admission; or

(c) application for medicaid is made subsequent to admission.

(E) Decisions made by the medical review entity as described in this rule are appealable to the medical review entity and are subject to the reconsideration process described in rule 5160-2-12 of the Administrative Code.

(F) Recipients have a right to a hearing in accordance with division 5101:6 of the Administrative Code. This hearing is separate and distinct from the provider's appeal, as described in paragraph (E) of this rule.

(G) Reimbursement subject to pre-certification review.

(1) The payment for treatment is contingent upon the acceptance of the reviewing agency's recommendation on the appropriate service location and the medical necessity of the admission.

(2) A certification that an inpatient stay is medically necessary does not guarantee payment for that service. The individual has to be a medicaid recipient at the time the service is rendered, and the service has to be a covered service.

(3) A psychiatric admission, as defined in paragraph (A)(4) of this rule, is reimbursed according to the rates for inpatient hospital services pursuant to rule 5160-2-65 of the Administrative Code for hospital admissions reimbursed on a prospective basis. Qualified provider services are reimbursed according to medicaid maximums for physician services pursuant to appendix DD to rule 5160-1-60 of the Administrative Code.

(4) In any instance when an admission that needs pre-certification occurs and the admission has not been approved, hospital payments will not be made. If separate professional provider payments have been made for services associated with the medically unnecessary admission, such payments will be recovered by ODM. Recipients should not be billed for charges associated with the admission except under circumstances described in paragraph (G)(5) of this rule.

(5) If the pre-certification process is initiated prospectively by the provider and hospital inpatient services are denied, or if an admission requiring pre-certification is not found to be medically necessary and the recipient chooses hospitalization, this admission and all associated services would be considered noncovered services and the recipient may be liable for payment of these services in accordance with rule 5160-1-13.1 of the Administrative Code.

Last updated June 13, 2022 at 12:27 PM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 6/12/2027
Prior Effective Dates: 10/19/1987, 7/1/1990, 1/1/2000, 4/30/2015

Rule 5160-2-60 | Hospital cost coverage add-on.

• Effective: January 1, 2024
• Promulgated Under: 119.03

Effective for services or discharges on or after the effective date of this rule, payments made to Ohio hospitals under the prospective payment systems or non-diagnostic related groups (DRG) and non-ambulatory patient grouping (EAPG) prospective payment systems will receive a cost coverage add-on. The provisions of this rule do not apply to the medicaid maximum allowed amount calculation described in rule 5160-2-25 of the Administrative Code.

(A) Definitions.

(1) "Inpatient case mix" means the sum of the relative weight values for all discharges during the calendar year preceding the calendar year that precedes the state fiscal year (SFY) of the cost coverage add-on divided by the total number of discharges during the same calendar year.

(2) "Freestanding psychiatric hospital" means a privately-owned psychiatric hospital with more than sixteen beds that is eligible to provide medicaid services as described in rule 5160-2-01 of the Administrative Code.

(3) "Outpatient case mix" means the sum of the relative weight values for each enhanced ambulatory patient grouping (EAPG) detail line paid with a relative weight during the calendar year preceding the calendar year that precedes the state fiscal year of the cost coverage add-on divided by the total number of EAPG detail lines paid with a relative weight during the same calendar year.

(4) "Total medicaid inpatient discharges" for each hospital means the sum of medicaid fee for service (FFS) discharges reported on "Ohio Medicaid Hospital Cost Report" ODM 02930, schedule C-1, section I, columns 2 and 3, line 54 for the applicable SFY and medicaid managed care plan (MCP) discharges reported on ODM 02930, schedule C-1, section I, columns 6 and 7, line 54.

(5) "Total medicaid inpatient charges" for each hospital means the sum of FFS medicaid inpatient charges reported on ODM 02930, schedule H, column 1, line 8 and MCP inpatient charges reported on ODM 02930, schedule I, column 2, line 202.

(6) "Total medicaid outpatient charges" for each hospital means the sum of FFS medicaid outpatient charges reported on ODM 02930, schedule H, column 1, line 16 and MCP outpatient charges reported on ODM 02930, schedule I, column 4, line 202.

(7) "Total medicaid inpatient costs" for each hospital means the sum of FFS medicaid inpatient costs reported on ODM 02930, schedule H, column 1, line 1 and MCP inpatient costs reported on ODM 02930, schedule I, column 3, line 202.

(8) "Total medicaid outpatient costs" for each hospital means the sum of FFS medicaid outpatient costs reported on ODM 02930, schedule H, column 1, line 10 and MCP outpatient costs reported on ODM 02930, schedule I, column 5, line 202.

(9) "Total medicaid outpatient visits" for each hospital means the sum of medicaid FFS visits reported on ODM 02930, schedule C-1, section I, columns 2 and 3, line 56 and medicaid MCP visits reported on ODM 02930, schedule I, column 4, line 205.

(B) Source data for calculations

The calculations described in this rule will be based on cost-reporting data described in rule 5160-2-23 of the Administrative Code, which reflects the interim settled Ohio medicaid hospital cost report (ODM 02930) for each hospital's cost reporting period ending in the SFY prior to the SFY that ends immediately preceding the SFY to which the cost coverage add-on will apply. The data policies described in rules 5160-2-08 and 5160-2-09 of the Administrative Code that use the same cost report data described in this paragraph will apply to the data used for the cost coverage add-on, except for hospitals that have closed or are known to be closing.

(C) The appropriations authorized by the general assembly for each SFY will be divided into the following policy pools:

(1) Inpatient cost coverage standard pool, which is the lesser of 259,229,112.31 dollars or 36.38 per cent of the appropriated funds.

(2) Outpatient cost coverage standard pool, which is the lesser of 168,054,601.29 dollars or 23.59 per cent of the appropriated funds.

(3) Cost coverage sustainability pool is the sum of:

(a) The lesser of 233,000,000.00 dollars or 32.70 per cent of the appropriated funds; and

(b) The greater of 7.33 per cent or the balance of the appropriated funds.

(4) Freestanding psychiatric hospitals as described in paragraph (A)(2) of this rule will receive 1.86 per cent of the amount described in paragraph (C)(3)(b) of this rule.

(D) Inpatient cost coverage.

(1) Cost coverage standard pool.

(a) From the amount specified in paragraph (C)(1) of this rule, 15,939,479.00 dollars will be allocated to children's hospitals, as defined in rule 5160-2-05 of the Administrative Code, based on the payments made to each children's hospital from funds specifically appropriated by Am. Sub. HB 49 of the 132nd General Assembly.

(b) Each hospital will be allocated from paragraph (C)(1) of this rule, an amount equal to the inpatient non-claims specific lump sum payments not resulting from an alternative payment model or the hospital care assurance program (HCAP) as described in rule 5160-1-70 or 5160-2-09 of the Administrative Code, less the amount allocated in paragraph (D)(1)(a) of this rule.

(c) Any amounts in paragraph (D)(1)(b) of this rule allocated to a closed hospital are reallocated to the remaining hospitals based on the ratio of each hospital's allocation in paragraph (D)(1)(b) of this rule to the sum of the allocation for all remaining hospitals.

(d) For each hospital, sum the amount allocated in paragraphs (D)(1)(a) to (D)(1)(c) of this rule.

(2) Divide ten per cent of the cost coverage sustainability pool described in paragraph (C)(3) of this rule by the total medicaid discharges for all hospitals, then multiply the resulting quotient by the number of total medicaid discharges for each hospital.

(3) For freestanding psychiatric hospitals, divide the amount described in paragraph (C)(4) of this rule by the total medicaid discharges for all freestanding psychiatric hospitals, then multiply the resulting quotient by the number of medicaid discharges for each freestanding psychiatric hospital.

(E) Outpatient cost coverage.

(1) Cost coverage standard pool.

(a) Each hospital will be allocated from paragraph (C)(2) of this rule an amount equal to the outpatient non-claims specific lump sum payments not resulting from an alternative payment model or HCAP as described in rule 5160-1-70 or 5160-2-09 of the Administrative Code.

(b) Any amounts in paragraph (E)(1)(a) of this rule allocated to a closed hospital are reallocated to the remaining hospitals based on the ratio of each hospital's allocation in paragraph (E)(1)(a) of this rule to the sum of the allocation for all remaining hospitals.

(c) For each hospital, sum the amount allocated in paragraph (E)(1)(a) of this rule and the amount calculated in paragraph (E)(1)(b) of this rule.

(2) Divide ninety per cent of the cost coverage sustainability pool described in paragraph (C)(3) of this rule less the amount described in paragraph (C)(4) of this rule by the total medicaid visits for all hospitals, then multiply the resulting quotient by the number of total medicaid visits for each hospital.

(F) Inpatient cost coverage add-on amount per discharge for hospitals paid in accordance with rule 5160-2-65 of the Administrative Code.

(1) For each hospital, divide the sum of paragraphs (D)(1) to (D)(3) of this rule by the total medicaid discharges used in the inpatient case-mix calculation as described in paragraph (A)(1) of this rule.

(2) For each hospital, divide the results in paragraph (F)(1) of this rule by the inpatient case-mix as defined in paragraph (A)(1) of this rule.

(3) The cost coverage add-on per discharge amount is equal to the amount calculated in paragraph (F)(2) of this rule, rounded to two decimal places.

(4) The amount calculated in paragraph (F)(3) of this rule will be added to the hospital's inpatient base rate.

(G) Outpatient cost coverage add-on amount per detail for hospitals paid in accordance with rule 5160-2-75 of the Administrative Code.

(1) For each hospital, divide the sum of paragraphs (E)(1) and (E)(2) of this rule by the total EAPG detail lines used in the outpatient case-mix calculation as described in paragraph (A)(3) of this rule.

(2) For each hospital, divide the results in paragraph (G)(1) of this rule by the outpatient case-mix as defined in paragraph (A)(3) of this rule.

(3) The cost coverage add-on per detail amount is equal to the amount calculated in paragraph (G)(2) of this rule, rounded to two decimal places.

(4) The amount calculated in paragraph (G)(3) of this rule will be added to the hospital's outpatient base rate.

(H) Inpatient cost coverage add-on for hospitals paid in accordance with rule 5160-2-22 of the Administrative Code.

(1) For each hospital, calculate total inpatient payments by multiplying total medicaid inpatient charges as described in paragraph (A)(5) of this rule by the inpatient cost-to-charge ratio described in rule 5160-2-22 of the Administrative Code calculated from the source data described in paragraph (B) of this rule.

(2) For each hospital, divide the amount in paragraph (H)(1) of this rule by the total medicaid inpatient costs as described in paragraph (A)(7) of this rule.

(3) For each hospital, sum the inpatient payments calculated in paragraph (H)(1) of this rule and the amounts distributed in paragraphs (D)(1) to (D)(3) of this rule.

(4) For each hospital, divide the result in paragraph (H)(3) of this rule by the total medicaid inpatient costs as described in paragraph (A)(7) of this rule.

(5) For each hospital, calculate the inpatient cost coverage increase by subtracting the result in paragraph (H)(2) of this rule from the result in paragraph (H)(4) of this rule and dividing the result by paragraph (H)(2) of this rule, rounded to four decimal places.

(6) For each hospital, multiply the result in paragraph (H)(5) of this rule by the inpatient cost-to-charge ratio calculated in paragraph (H)(1) of this rule.

(7) Apply the amount calculated in paragraph (H)(6) of this rule as an increase to the hospital's inpatient cost-to-charge ratio as follows:

(a) For each July first, the hospital's inpatient cost-to-charge ratio calculated the previous January in accordance with rule 5160-2-22 of the Administrative Code.

(b) For each January first, the hospital's inpatient cost-to-charge ratio as calculated in rule 5160-2-22 of the Administrative Code.

(I) Outpatient cost coverage add-on for hospitals paid in accordance with rule 5160-2-22 of the Administrative Code.

(1) For each hospital, calculate total outpatient payments by multiplying total medicaid outpatient charges as described in paragraph (A)(6) of this rule by the outpatient cost-to-charge ratio described in rule 5160-2-22 of the Administrative Code calculated from the source data described in paragraph (B) of this rule.

(2) For each hospital, divide the amount in paragraph (I)(1) of this rule by the total medicaid outpatient costs as described in paragraph (A)(8) of this rule.

(3) For each hospital, sum the outpatient payments calculated in paragraph (I)(1) of this rule and the distribution pools in paragraphs (E)(1) and (E)(2) of this rule.

(4) For each hospital, divide the result in paragraph (I)(3) of this rule by the total medicaid outpatient costs as described in paragraph (A)(8) of this rule.

(5) For each hospital, calculate the outpatient cost coverage increase by subtracting the result in paragraph (I)(2) of this rule from the result in paragraph (I)(4) of this rule and dividing the result by paragraph (I)(2) of this rule, rounded to four decimal places.

(6) For each hospital, multiply the result in paragraph (I)(5) of this rule by the outpatient cost-to-charge ratio calculated in paragraph (I)(1) of this rule.

(7) Apply the amount calculated in paragraph (I)(6) of this rule as an increase to the hospital's outpatient cost-to-charge ratio as follows:

(a) For each July first, the hospital's outpatient cost-to-charge ratio calculated the previous January in accordance with rule 5160-2-22 of the Administrative Code.

(b) For each January first, the hospital's outpatient cost-to-charge ratio as calculated in rule 5160-2-22 of the Administrative Code.

(J) To ensure that funds appropriated for the cost coverage add-on are fully expended in support of the intended purpose, the department may make short term adjustments to increase or decrease hospital-specific rates. Such adjustments will be calculated in accordance with the cost coverage sustainability pool as described in paragraphs (D)(2) and (E)(2) of this rule. The number of discharges or visits used to establish a case-mix adjusted hospital-specific rate, may be adjusted to reflect the time period for which the rate will be in effect. Any such adjustments will be developed in consultation with the department's actuary and approved by the medicaid director.

Last updated January 2, 2024 at 8:53 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5164.02
Five Year Review Date: 1/2/2025
Prior Effective Dates: 7/4/2021

Rule 5160-2-65 | Inpatient hospital reimbursement.

• Effective: July 1, 2024
• Promulgated Under: 119.03

This rule sets forth the payment policies for inpatient hospital services for discharges on or after the effective date of this rule.

(A) Hospitals defined as eligible providers of hospital services in rule 5160-2-01 of the Administrative Code and grouped in paragraph (B)(1) of rule 5160-2-05 of the Administrative Code are subject to the all patient refined diagnosis related groups (APR-DRG) prospective payment methodology as described in this rule.

(B) Hospital peer groups. For purposes of setting rates and making payments under the APR-DRG prospective payment system, the Ohio department of medicaid (ODM) classifies all hospitals not defined in paragraph (A) of this rule into one of the mutually exclusive peer groups defined in this paragraph.

(1) Children's hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(2) Children's hospitals as defined in rule 5160-2-05 of the Administrative Code that are not located in Ohio.

(3) Critical access hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(4) Rural hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(5) Teaching hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(6) Teaching hospitals as defined in rule 5160-2-05 of the Administrative Code that are not located in Ohio.

(7) Urban hospitals as defined in rule 5160-2-05 of the Administrative Code that are located in Ohio.

(8) For purposes of this rule, freestanding psychiatric hospitals (FSPs) as defined in rule 5160-2-05 of the Administrative Code are so named for the implementation of special payment policies as described in this rule.

(9) All other hospitals that are not located in Ohio that are not classified in paragraph (B)(2) or (B)(6) of this rule.

(C) DRG/severity of illness assignment.

(1) Each discharge is assigned a DRG and one of four severity of illness (SOI) factors based upon the date of discharge.

(2) If a claim submitted by a hospital is deemed ungroupable because it does not contain valid values for one or more of the variables needed by the APR-DRG grouper, then the claim will be denied payment by ODM.

(D) Payment formula.

(1) The formula used in the APR-DRG prospective payment system is as follows: total payment, rounded to the nearest whole penny, equals (a) base payment plus (b) capital allowance plus (c) medical education allowance (if hospital is eligible) plus (d) outlier payment (if applicable) plus (e) other payments for organ transplants where;

(a) Base payment equals the hospital base rate as described in paragraph (G) of this rule multiplied by the corresponding relative weight for the DRG/SOI as described in paragraph (H) of this rule.

(b) Capital allowance equals the per case add-on as described in paragraph (J) of this rule.

(c) Medical education allowance equals the per case add-on, case mix adjusted, as described in paragraph (K) of this rule.

(d) Outlier payment equals the eligible outlier costs multiplied by the outlier payment percentage as described in paragraph (I) of this rule.

(e) Other payments for transplant related services as described in paragraph (L) of this rule.

(2) The formula used for per diem payments is described in paragraph (M) of this rule.

(E) Payments under the prospective payment system are made on the basis of a prospectively determined rate as provided in this rule. No year-end retrospective adjustment is made for prospective payments. Except as provided in rules 5160-2-24, 5160-2-13, and 5160-2-40 of the Administrative Code, a hospital may keep the difference between its prospective payment rate and costs incurred in furnishing inpatient services and is at risk for costs which exceed the prospective payment amounts.

(F) Sources for inputs in the payment formula.

(1) The dataset used as inputs in the determination of hospital base rates consists of:

(a) Inpatient hospital claims with dates of discharge from January 1, 2018 through December 31, 2021;

(b) Cost reports submitted by hospitals to ODM on its medicaid cost report for the hospital years that end in state fiscal years 2019 (ODM 02930 rev. 5/2019), 2020 (ODM 02930 rev. 5/2020), 2021 (ODM 02930 rev. 5/2021) and 2022 (ODM 02930 rev. 5/2022); and

(c) Inflation factors computed for Ohio by a nationally-recognized research firm that computes similar factors for the medicare program. The inflation factors were used to apply an inflationary value to the total cost computed for each case inflating it to December 31, 2023.

(2) The dataset used as inputs in the determination of relative weights consists of:

(a) Inpatient hospital claims with dates of discharge from January 1, 2018 through December 31, 2021;

(b) Cost reports submitted by hospitals to ODM on its medicaid cost report for the hospital years that end in state fiscal years 2019 (ODM 02930 rev. 5/2019), 2020 (ODM 02930 rev. 5/2020), 2021 (ODM 02930 rev. 5/2021) and 2022 (ODM 02930 rev. 5/2022); and

(c) Inflation factors computed for Ohio by a nationally-recognized research firm that computes similar factors for the medicare program. The inflation factors were used to apply an inflationary value to the total cost computed for each case inflating it to December 31, 2023.

(G) Computation of hospital peer group base rates.

(1) The base rate for Ohio children's hospitals is equal to:

(a) Fifty-two and three hundredths per cent of the total inflated costs for the cases assigned to a children's hospital divided by the number of cases assigned to the children's hospital; divided by

(b) The peer group case mix score as calculated in paragraph (G)(5) of this rule.

(2) The base rate for Ohio teaching hospitals as described in rule 5160-2-05 of the Administrative Code is equal to:

(a) Fifty-eight and three tenths per cent of the total inflated costs for the cases assigned to a teaching hospital divided by the number of cases assigned to the teaching hospital; divided by

(b) The peer group case mix score as calculated in paragraph (G)(5) of this rule.

(3) The base rate for each Ohio FSP hospital is equal to:

(a) Ninety and thirty-two hundredths per cent of the total inflated costs for the cases assigned to a hospital divided by the number of cases assigned to the FSP hospital; divided by

(b) The case mix score as calculated in paragraph (G)(6) of this rule.

(4) The base rate for hospitals in Ohio peer groups other than children's, teaching or FSP hospitals is equal to:

(a) Forty-nine and three tenths per cent of the total inflated costs for the cases assigned to a peer group; divided by the number of cases in the peer group; divided by

(b) The peer group case mix score as calculated in paragraph (G)(5) of this rule.

(5) The peer group case mix score is equal to:

(a) The sum of the relative weight values across all cases assigned to a peer group; divided by

(b) The number of cases in the peer group.

(6) For non-Ohio hospital peer groups, the peer group base rate is equal to the value assigned to the peer group effective January 1, 2024. For dates of service on or after the effective date of this rule, the amount will be equal to;

(a) For non-Ohio children's hospitals, eighty-seven and thirty-nine hundredths per cent of the base rate in effect on the effective date of this rule for Ohio children's hospitals.

(b) For non-Ohio teaching hospitals, eighty-five and seventy-one hundredths per cent of the base rate in effect on the effective date of this rule for Ohio teaching hospitals.

(c) For all other non-Ohio hospitals, seventy-six and seventy-three hundredths per cent of the base rate in effect on the effective date of this rule of Ohio hospitals that are not considered teaching, children's and psychiatric hospitals.

(7) The statewide per diem rate for each FSP hospital is equal to:

(a) Eighty-nine and six tenths per cent of the total inflated costs for all cases; divided by

(b) The total length of stay (LOS) for all cases.

(8) The FSP peer group per diem rate for each peer group defined in paragraphs (B)(4) and (B)(7) of this rule is equal to:

(a) Between eighty-eight and twenty-nine hundredths per cent and ninety-six and ninety-three hundredths per cent of total inflated costs for all cases, dependent upon the peer group; divided by

(b) The total LOS for all cases within the peer group.

(H) The computation of relative weights for all DRGs is equal to:

(1) The average inflated cost per case within the DRG/SOI; divided by

(2) The average inflated cost per case across all DRG/SOIs.

(3) ODM computed two sets of relative weights:

(a) One set of relative weights within the behavioral health and substance use disorder (BH/SUD) DRGs 740-776. The average relative weight within the BH/SUD DRGs was adjusted to eighty per cent of the natural result.

(b) One set of relative weights for acute care DRGs.

(I) Computation of outlier payments.

(1) If a discharge is eligible for an outlier payment, the payment will be equal to eighty per cent of the value of eligible outlier costs.

(2) Eligible outlier costs are equal to the cost of the case minus an outlier threshold.

(a) When discharges are submitted for payment by hospitals, the cost of the case is computed as the product of covered billed charges and a hospital-specific medicaid inpatient cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code.

(b) The outlier threshold is equal to the base payment as described in paragraph (D)(1)(a) of this rule plus a fixed outlier threshold as described in paragraph (I)(2)(c) of this rule.

(c) The fixed outlier threshold varies and can be either DRG specific or peer group specific. The fixed outlier threshold for neonate and tracheostomy DRGs is fifty thousand dollars. The fixed outlier threshold for cases other than neonate and tracheostomy billed by hospitals among other peer groups is seventy-five thousand dollars.

(3) For any claim that qualifies for an outlier payment, the final claim payment will be limited to the lesser of covered billed charges or the total payment calculated in paragraph (D)(1) of this rule.

(J) Computation of capital payments.

(1) For Ohio hospitals, a capital allowance will be paid as described in rule 5160-2-66 of the Administrative Code.

(2) For non-Ohio hospitals a capital allowance will be paid as described in rule 5160-2-66 of the Administrative Code.

(K) Computation of medical education payments.

(1) For Ohio hospitals, a medical education allowance will be paid as described in rule 5160-2-67 of the Administrative Code.

(2) For non-Ohio hospitals, the calculated base rate as described in paragraph (G)(6) of this rule includes an allowance for medical education.

(L) Other payments for transplant related services.

(1) Reimbursement for all organ transplant services, except for kidney transplants, is contingent upon review and recommendation by the "Ohio Solid Organ Transplant Consortium" based on criteria established by Ohio organ transplant surgeons and authorization from ODM.

(2) Reimbursement for bone marrow transplant and hematopoietic stem cell transplant is contingent upon review and the recommendation by the "Ohio Hematopoietic Stem Cell Transplant Consortium" based on criteria established by Ohio experts in the field of bone marrow transplant and authorization from ODM. Reimbursement is further contingent upon:

(a) Membership in the "Ohio Hematopoietic Stem Cell Transplant Consortium"; or

(b) Compliance with the performance standards described in agency 3701 of the Administrative Code, and the performance of ten autologous or ten allogeneic bone marrow transplants, dependent on which volume criteria is appropriate for the transplant requested.

(3) Organ acquisition and transportation costs for heart, heart/lung, liver, pancreas, single/double lung, and liver/small bowel transplant services will be reimbursed at one hundred per cent of billed charges.

(4) For harvesting costs for bone marrow transplant services, the prospective payment amount will be either:

(a) The DRG amount as described in this rule if the donor is a medicaid recipient or if the bone marrow transplant is autologous.

(b) The product of the covered billed charges times the hospital-specific, medicaid inpatient cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code, if the donor is not a medicaid recipient.

(M) Other payment policies.

(1) A claim for inpatient services qualifies for interim payment on the thirtieth day of a consecutive inpatient stay and at thirty-day intervals thereafter. Under interim payment, hospitals will be paid on a percentage basis of charges. The percentage will represent the hospital-specific medicaid inpatient cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code. For those hospitals which do not file a cost report under the provisions of rule 5160-2-23 of the Administrative Code, the statewide average medicaid inpatient cost-to-charge ratio as described in rule 5160-2-22 of the Administrative Code will be used. Interim payments are made as a credit against final payment of the final discharge bill. Amounts of difference between interim payment made and the prospective payment described in paragraph (A) of this rule for the final discharge will be reconciled when the final discharge bill is processed.

(2) Payments for transfers as defined in rule 5160-2-02 of the Administrative Code are subject to the following provisions. If a hospital paid under the prospective payment system transfers an inpatient to another hospital or receives an inpatient from another hospital and that transfer is appropriate as defined in rule 5160-2-13 of the Administrative Code, then each hospital is paid a per diem rate for each day of the patient's stay in that hospital, plus capital, medical education and outlier allowances, as applicable, not to exceed, for nonoutlier cases, the final prospective payment rate that would have been paid for the appropriate DRG/SOI as described in paragraph (D) of this rule. When a patient is transferred, ODM's payment is based on the DRG/SOI under which the patient was treated at each hospital.

The per diem rate is determined by dividing the product of the hospital's base rate multiplied by the DRG/SOI relative weight as described in this rule by the statewide average length of stay calculated for the specific DRG/SOI into which the case falls.

For inpatient services provided to patients who are discharged, within the same hospital, from an acute care bed and admitted to a bed in a psychiatric unit distinct part, payment will be made based on the DRG representing services provided in the acute care section and the services provided in the psychiatric unit distinct part.

Transfers received by or discharging from a freestanding psychiatric hospital are not subject to the provisions of paragraph (M)(2) of this rule. For transfers from one unit of a hospital to another distinct unit of the same hospital, the claim with an admit source indicating that the transfer results in a separate claim to medicaid is not subject to the provisions of paragraph (M)(2) of this rule, provided that the discharge status does not indicate transfer.

(3) The per diem rates for the FSPs are calculated based on the sum of all the amounts calculated in paragraph (D) of this rule plus the eligible hospital specific add-on amounts in accordance with rule 5160-2-60 of the Administrative Code, divided by the total days for these claims in the rate setting database. As a transitional step, FSPs may be paid the resulting value in accordance with paragraph (D) of this rule.

The FSP per diem payment is calculated by multiplying each covered billed day by the per diem rate as described in paragraph (G) of this rule.

(4) In instances when a recipient's eligibility begins after the date of admission to the hospital or is terminated during the course of a hospitalization, payment will be made on a per diem basis as described in paragraph (M)(2) of this rule plus the allowance for capital, medical education and outliers, as applicable.

(5) Readmissions are defined in rule 5160-2-02 of the Administrative Code. A readmission within one calendar day of discharge, to the same institution, is considered to be one discharge for payment purposes so that one DRG payment is made. If two claims are submitted, the second claim processed will be rejected. In order to receive payment for the entire period of hospitalization, the hospital will need to submit an adjustment claim reflecting services and charges for the entire hospitalization.

(6) In the case of deliveries, hospitals submit separate claims based respectively on the mother's individual eligibility and the child's individual eligibility.

(N) Adjustments to relative weights.

(1) In accordance with section 5164.721 of the Revised Code, long-acting reversible contraceptive (LARC) devices may be billed and paid separately when provided during an inpatient hospitalization.

(2) In accordance with section 5164.072 of the Revised Code, the relative weights for neonate DRGs 580-640 with an SOI of major or extreme, as calculated in paragraph (H) of this rule, were increased by five and thirteen hundredths per cent to provide for enhanced payments for donor breast milk and milk fortifiers.

Last updated July 2, 2024 at 10:43 AM

Supplemental Information

Authorized By: 119.03
Amplifies: 5164.02, 5164.70
Five Year Review Date: 7/1/2029
Prior Effective Dates: 1/1/2017

Rule 5160-2-66 | Capital costs.

• Effective: January 1, 2024
• Promulgated Under: 119.03

This rule outlines the calculation of capital payments for hospitals that are subject to the all patient refined diagnosis related groups (APR-DRG) prospective payment methodology, effective for dates of discharges occurring on or after January 1, 2024.

(A) For purposes of this rule, capital costs include the categories of costs recognized by medicare on the centers for medicare and medicaid services (CMS) CMS 2552-10 revised October 2016 and filed in accordance with CMS instructions, available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals.html (revised June 2022).

(B) Capital-related costs for services provided by Ohio hospitals paid under prospective payment will be subject to prospective payment without subsequent settlement to actual capital costs.

(C) Annual update of interim capital payments.

(1) The calculation of interim capital payments resulting in the capital allowance identified in rule 5160-2-65 of the Administrative Code is based on the hospital's cost-reporting period.

On an annual basis, the interim capital payments will be redetermined by identifying eighty-five per cent of the capital-related costs reported on the ODM 02930, "Ohio Medicaid Hospital Cost Report"; multiplying that cost by the per cent of the sum of the medicaid inpatient charges to total charges; and dividing the result by the sum of the number of medicaid discharges that occurred during the cost-reporting period. The cost report used to complete these calculations is the interim settled cost report ending in the state fiscal year ending in the calendar year preceding the immediate past calendar year prior to January first of the calendar year to which the new capital rate will apply.

(D) Non-Ohio hospital capital reimbursement.

(1) The average statewide capital cost is computed by summing, for all Ohio hospitals, the identified capital costs as described in paragraph (C) of this rule and multiplying that cost by the per cent of the sum of medicaid inpatient charges to total charges for all Ohio hospitals, and dividing by total discharges for all Ohio hospitals as described in paragraph (C) of this rule.

(2) The capital allowance for non-Ohio hospitals will be eighty-five per cent of the amount calculated in paragraph (D)(1) of this rule.

(3) The average statewide capital cost is updated annually using capital costs from cost reports as described in paragraph (C) of this rule.

(4) The amounts derived in paragraph (D) of this rule will reflect a statewide average calculated to be in effect at the beginning of the prospective rate year and not subject to retrospective adjustments.

Last updated January 2, 2024 at 8:53 AM

Supplemental Information

Authorized By: 119.03
Amplifies: 5164.02, 5164.70
Five Year Review Date: 1/1/2029
Prior Effective Dates: 10/19/1987, 1/27/2006, 7/1/2017

Rule 5160-2-67 | Medical education.

• Effective: December 16, 2017
• Promulgated Under: 119.03

Effective for dates of discharge on or after the effective date of this rule, to qualify for a medical education payment as described in this rule, Ohio hospitals must have an approved medical education program as defined in 42 C.F.R. 415.152 (October 1, 2016) and the costs of the approved medical education program were reflected in their state fiscal year (SFY) 2014 Ohio medicaid hospital cost report (ODM 02930 rev. 6/2014). This rule describes the methodology used for computing the direct graduate medical education and indirect medical education components of each hospital's medical education add-on rate.

(A) Computation of direct graduate medical education (DGME) costs, which are the costs that are directly related to the training of interns and residents and allied professionals in an approved medical education program.

(1) Tabulate the costs captured on the ODM 02930 for interns and residents and allied professionals.

(2) Tabulate the total facility charges and total medicaid fee-for-service and managed care charges reported on the ODM 02930. Calculate the medicaid factor by dividing the sum of total medicaid fee-for-service and managed care charges by total charges.

(3) Tabulate the total medicaid fee-for-service and managed care discharges from the ODM 02930.

(4) The medicaid portion of DGME costs equal the total DGME costs as described in paragraph (A)(1) of this rule multiplied by the medicaid factor as described in paragraph (A)(2) of this rule.

(5) A cost per discharge is computed using the medicaid portion of DGME costs as described in paragraph (A)(4) of this rule divided by the total number of medicaid discharges as described in paragraph (A)(3) of this rule.

(B) Computation of indirect medical education (IME) costs, which are the costs that recognize the increased costs of patient care that results from operating an approved medical education program.

(1) Identify the number of interns and residents and number of beds reported on the ODM 02930.

(2) Compute the IME factor by using the logarithmic formula 1.35 * ((1+((interns and residents)/beds)^0.405)-1).

(3) Tabulate the total medicaid fee-for-service and managed care net operating costs reported on the ODM 02930.

(4) The medicaid portion of IME is the medicaid net operating costs as described in paragraph (B)(3) of this rule multiplied by the IME factor as described in paragraph (B)(2) of this rule.

(5) A cost per discharge is computed using the medicaid portion of IME costs as described in paragraph (B)(4) of this rule divided by the total number of medicaid discharges as described in paragraph (A)(3) of this rule.

(a) The IME cost per discharge is capped. The capped value is the statewide mean IME cost per discharge plus one standard deviation.

(b) If the hospital's IME cost per discharge is greater than the capped IME cost per discharge as described in paragraph (B)(5)(a) of this rule, then the hospital's IME cost per discharge is equal to the capped IME cost per discharge as described in paragraph (B)(5)(a) of this rule.

(C) Case-mix adjustment of medical education add-on rate.

(1) The case-mix score for each hospital equals the sum of the relative weight values for all SFY 2014 discharges divided by the total number of medicaid discharges as described in paragraph (A)(3) of this rule.

(2) Sum the DGME cost per discharge as described in paragraph (A)(5) of this rule and the IME cost per discharge as described in paragraph (B)(5) of this rule.

(3) Divide the sum of the DGME cost per discharge and IME cost per discharge as described in paragraph (C)(2) of this rule by the case-mix score as described in paragraph (C)(1) of this rule. The resulting value is the hospital's total medical education add-on rate.

(4) The hospital's total medical education add-on rate as described in paragraph (C)(3) of this rule shall be subject to a payment neutrality adjustment of fifty-nine and seven-tenths per cent.

(D) Medical education and stop-loss/stop-gain.

(1) For each hospital, determine the total value of current medical education payments as reimbursed by the all patient refined diagnosis related groups prospective payment system prior to July 1, 2017 by multiplying the hospital's medical education add-on rate effective January 1, 2017 by the hospital's case-mix score in effect prior to July 1, 2017 by the total number of medicaid discharges for the twelve month period used to estimate the fiscal impact.

(2) Determine the hospital's projected medical education payments by multiplying the case-mix adjusted medical education add-on rate as described in paragraph (C) of this rule by the total number of medicaid discharges for the twelve month period used to estimate the fiscal impact.

(3) If the hospital's current medical education payments as described in paragraph (D)(1) of this rule are greater than the projected medical education payments as described in paragraph (D)(2) of this rule, then the hospital's medical education add-on rate shall be the medical education add-on rate used to calculate current medical education payments as described in paragraph (D)(1) of this rule.

(4) If the hospital's projected medical education payments as described in paragraph (D)(2) of this rule are more than one-hundred and ten per cent of current medical education payments as described in paragraph (D)(1) of this rule, then the hospital's medical education payments shall be the current medical education add-on rate multiplied by one-hundred and ten per cent.

(5) If the hospital's projected medical education payments as described in paragraph (D)(2) of this rule are greater than its current medical education payments as described in paragraph (D)(1) of this rule but less than one-hundred and ten per cent of its current medical education payments as described in paragraph (D)(1) of this rule, then the hospital's medical education add-on rate is the add-on rate used to calculate projected medical education payments as described in paragraph (D)(2) of this rule.

(E) Recognition of approved medical education programs outside of rebasing.

(1) For rate years when a rebasing is not being conducted, hospitals that have added an approved graduate medical education program and demonstrate such costs on the interim-settled cost report that ends in the SFY ending in the calendar year preceding the immediate past calendar year prior to January first of the rate year, the interim medical education add-on rate shall be the sum of eighty per cent of the statewide average DGME add-on rate plus fifty per cent of the statewide average IME add-on rate.

(2) For a hospital that only demonstrates costs for medical education of allied professionals on the interim-settled cost report that ends in the SFY ending in the calendar year preceding the immediate past calendar year prior to January first of the rate year, the medical education add-on rate will be fifty per cent of the statewide average DGME add-on rate.

(3) For a hospital that has a newly approved graduate medical education program but whose costs are not yet reflected on a cost report, the medical education add-on rate will be fifty per cent of the statewide average DGME add-on rate.

(a) A hospital with a newly approved graduate medical education program must notify the department no later than October first of the calendar year immediately preceding January first of the rate year.

(b) Notification to the department must include documentation from the "Accreditation Council of Graduate Medical Education" that the hospital has an approved medical education program or documentation of medicare's recognition of the hospital's approved full-time equivalent interns and residents count, or both.

(4) For a hospital whose interim-settled cost report that ends in the SFY ending in the calendar year preceding the immediate past calendar year prior to January first of the rate year no longer reflects costs for interns and residents, the medical education add-on rate will be reduced by the portion of the add-on rate that represented their IME costs.

(5) For a hospital whose interim-settled cost report that ends in the SFY ending in the calendar year preceding the immediate past calendar year prior to January first of the rate no longer reflects costs for interns and residents and allied professionals, the medical education add-on rate will be reduced to zero.

(F) The medical education payment is the product of a hospital's medical education add-on rate as described in either paragraph (C), (D), or (E) of this rule and the relative weight of the claim's assigned all patient refined diagnosis related group and severity of illness as described in rule 5160-2-65 of the Administrative Code.

Supplemental Information

Authorized By: 5164.02, 5164.74
Amplifies: 5162.03, 5164.02, 5164.74
Five Year Review Date: 7/6/2022
Prior Effective Dates: 1/20/1995, 7/6/2017

Rule 5160-2-75 | Outpatient hospital reimbursement.

• Effective: January 1, 2024
• Promulgated Under: 119.03

For purposes of this rule, eligible providers of hospital services as defined in rule 5160-2-01 of the Administrative Code and assigned to prospective payment peer group as described in rule 5160-2-05 of the Administrative Code are subject to the enhanced ambulatory patient grouping system (EAPG) prospective payment methodology utilized by the Ohio department of medicaid (ODM) as described in this rule.

(A) Definitions.

(1) "Enhanced ambulatory patient grouping (EAPG)" is a group of outpatient procedures, encounters, or ancillary services, which reflect similar patient characteristics and resource utilization, and which incorporate the use of international classification of diseases (ICD) diagnosis codes, current procedural terminology (CPT) code set and healthcare common procedure coding system (HCPCS) procedure codes.

(2) "EAPG grouper" is the software provided by 3M health information systems to group outpatient claims based on services performed and resource intensity.

(3) "Default EAPG settings" are the default EAPG grouper options in 3M's core grouping software for each EAPG grouper version.

(4) "Discounting factor" is a factor applicable for multiple significant procedures or repeated ancillary services designated by default EAPG settings or both. The appropriate percentage (fifty or one hundred per cent) will be applied to the highest weighted of the multiple procedures or ancillary services payment group.

(a) "Full payment" is the EAPG payment with no applicable discounting factor.

(b) "Consolidation factor" is a factor of zero per cent applicable for services designated with a same procedure consolidation flag or clinical procedure consolidation flag by the EAPG grouper under default EAPG settings.

(c) "Packaging factor" is a factor of zero per cent applicable for services designated with a packaging flag by the EAPG grouper under default EAPG settings.

(5) "EAPG base rate" is the dollar value that will be multiplied by the final EAPG weight for each EAPG on a claim to determine the total allowable medicaid payment for a visit.

(6) "Hospital peer groups" are for the purposes of setting rates and making payments under the EAPG or prospective payment system. ODM classifies all hospitals not excluded in rule 5160-2-05 of the Administrative Code into one of the mutually exclusive peer groups defined in this paragraph.

(a) Critical access hospitals as defined in rule 5160-2-05 of the Administrative Code.

(b) Rural hospitals as defined in rule 5160-2-05 of the Administrative Code.

(c) Children's hospitals as defined in rule 5160-2-05 of the Administrative Code.

(d) Teaching hospitals as defined in rule 5160-2-05 of the Administrative Code.

(e) Urban hospitals as defined in rule 5160-2-05 of the Administrative Code.

(f) All other hospitals not located in Ohio that are not classified in paragraphs (A)(6)(a) to (A)(6)(e) of this rule.

(7) "Outpatient claim" encompasses the outpatient services rendered to one eligible medicaid recipient on one date of service.

(8) "Outpatient invoice" is a bill submitted in accordance with Chapter 5160-1 of the Administrative Code, to ODM for services rendered to one eligible medicaid recipient on one or more date(s) of service. For an invoice encompassing more than one date of service, each date will be processed separately as an individual claim. An invoice should be limited to thirty calendar days.

(9) "Procedure code" is a CPT or HCPCS code as identified in rule 5160-1-19 of the Administrative Code. A list of covered procedure codes is published on ODM's website, http://medicaid.ohio.gov/.

(10) "Relative weight" is a factor specific to each EAPG that represents that EAPG's relative cost compared to an average case. The relative weights for all EAPGs are calculated as described in paragraph (F) of this rule.

(11) "Revenue center codes" are those in effect on the date of service and are listed in ODM's hospital billing guidelines as published on ODM's website, http://medicaid.ohio.gov/.

(B) EAPG payment formula.

The total EAPG payment is the product of the following for each detail line:

(1) Peer group base rate in paragraph (D)(2) of this rule or base rate as adjusted in paragraph (E) of this rule; multiplied by

(2) EAPG relative weight for which the service was assigned by the EAPG grouper, rounded to the nearest whole cent;

(3) Multiply the product of paragraphs (B)(1) and (B)(2) of this rule by the applicable discounting factor(s) as defined in paragraph (A)(4) of this rule;

(a) Laboratory services will be reimbursed the lesser of charges or the assigned EAPG payment.

(b) Radiology services will be reimbursed the lesser of charges or the assigned EAPG payment.

(4) Rounded to the nearest whole cent.

(C) Sources for inputs in the payment formula.

The dataset used as inputs in the payment formula and determination of relative weights established for dates of service on or after the effective date of this rule consists of:

(1) All outpatient hospital claims with dates of service from January 1, 2017, through June 30, 2021;

(2) Cost reports submitted by hospitals to ODM on its Ohio medicaid hospital cost report for the hospital years that end in state fiscal years 2017 (ODM 02930 rev. 4/2017) through 2021 (ODM 02930 rev. 5/2021); and

(3) Inflation factors computed for Ohio by a nationally recognized research firm that computes similar factors for the medicare program. The inflation factors were used to inflate the total cost computed for each case inflating it to June 30, 2024.

(D) Computation of case mix adjusted average cost per case (base rate).

(1) For each Ohio peer group, sum the total inflated cost for all cases; divided by

(2) The number of cases assigned to each peer group; and multiply the result as follows:

(a) For teaching hospitals, seventy per cent;

(b) For southeast hospitals, sixty-eight per cent;

(c) For southwest hospitals, sixty-three per cent; and

(d) For all other peer groups, sixty-two per cent.

(3) For each Ohio peer group, sum the relative weight values for all cases assigned to the peer group; divided by

(4) The number of cases in the peer group.

(5) For each Ohio peer group, multiply the amount described in paragraph (D)(2) of this rule by the result of paragraphs (D)(3) and (D)(4) of this rule.

(6) For non-Ohio peer groups, the peer group base rate is sixty-four per cent of the statewide average.

(E) Risk corridors.

Effective for dates of service on or after the effective date of this rule, ODM will apply the following to Ohio hospital peer groups except those defined in paragraphs (A)(6)(a) and (A)(6)(b) of this rule:

(1) If the peer group base rate calculated in paragraph (D) of this rule results in the fiscal impact at the individual hospital level that results in the reduction of payments from current levels, the individual hospital base rate is adjusted to a zero per cent reduction in payments; or

(2) If the peer group base rate calculated in paragraph (D) of this rule results in the fiscal impact at the individual hospital level that results in the increase of payments from current levels that is greater than ten per cent, the individual hospital base rate is adjusted to a ten per cent increase in payments.

(F) Computation of relative weights.

The relative weight is equal to:

(1) The average inflated cost per case within each EAPG; divided by

(2) The average inflated cost per case across all EAPGs.

(G) Items conditionally payable outside of EAPG.

(1) Pharmaceuticals.

(a) When applicable, reimbursement for provider-administered pharmaceuticals HCPCS J-code or Q-code billed with revenue center code 25X or 636 will be the lesser of charges or the payment amounts in the provider-administered pharmaceutical fee schedule as published on ODM's website, http://medicaid.ohio.gov/.

(b) Additional payments for pharmaceuticals will be made in accordance with the discounting factors as determined by the EAPG grouper.

(c) Pharmaceutical line items without a "National Drug Code" will be denied payment by ODM.

(d) Charges listed in line items that carry revenue center code 025X or 636 with a provider-administered pharmaceutical HCPCS J-code or Q-code that are not listed on the provider-administered pharmaceutical fee schedule or listed as "by report" will pay in accordance with paragraph (G)(3)(b)(iv) of this rule.

(2) Durable medical equipment (DME).

(a) Additional payments may be made for items grouping to a DME EAPG type.

(b) Reimbursement for outpatient hospital DME will be the lesser of charges or the payment amounts in the medicaid durable medical equipment fee schedule as published on ODM's website, http://medicaid.ohio.gov/.

(c) Additional payments for DME will be made in accordance with the discounting factors as determined by the EAPG grouper.

(3) Independently billed services for drugs or medical supplies and devices.

(a) To request independently billed payment under EAPG, hospitals will report all services provided on the date of service; and

(b) Report modifier UB with the primary procedure performed. Claims submitted with modifier UB are subject to the following payment methodology:

(i) Charges listed in line items that carry revenue center codes 025X or 0636 with a provider administered HCPCS J-code or Q-code will pay in accordance with the provider-administered pharmaceutical fee schedule.

(ii) Charges listed in line items that carry revenue center code 025X without a provider-administered pharmaceutical CPT/HCPCS code or revenue center code 027X with or without a DME HCPCS code will pay in accordance with paragraph (G)(3)(b)(iv) of this rule.

(iii) Charges listed in line items that carry revenue center code 025X or 0636 with a provider-administered pharmaceutical HCPCS J-code or Q-code that are not listed on the provider-administered pharmaceutical fee schedule or listed as "by report" will pay in accordance with paragraph (G)(3)(b)(iv) of this rule.

(iv) Payment for charges listed in paragraph (G)(3)(b)(ii) or (G)(3)(b)(iii) of this rule is the product of the following for each detail line:

(a) Allowed charges multiplied by the hospital's specific medicaid outpatient cost-to-charge ratio as described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code, rounded to the nearest whole cent.

(b) Multiply the product of paragraph (G)(3)(b)(iv)(a) of this rule by sixty per cent; rounded to the nearest whole cent.

(v) All other detail lines on the same date of service will be paid zero.

(4) Dental services.

Reimbursement for items assigned to a dental service EAPG type will be paid as follows:

(a) Children's hospitals, as defined in rule 5160-2-05 of the Administrative Code, will be paid one-thousand sixty-two dollars.

(b) All other hospitals will be paid one-thousand one-hundred ninety-two dollars.

(c) Payments will be multiplied by any applicable discounting factor, rounded to the nearest whole cent.

(5) Vaccines for children (VFC).

(a) The administration of immunizations covered under the VFC program may be reimbursed for recipients eighteen years or younger.

(b) Reimbursement for the administration of immunizations covered under the VFC program will be ten dollars for individuals eighteen years of age or younger, contingent upon the EAPG grouper. However, no payment will be made for vaccines that can be obtained at no cost through the federal VFC program.

(c) Additional payments for designated free vaccines will be made in accordance with the discounting factors as determined by the EAPG grouper.

(6) Observation services.

(a) Payment for observation services HCPCS code G0378 will be made using an average rate. Payment will be made for the following types of observation services:

(i) Acute care related observation services; and

(ii) Behavioral health (BH) and/or substance use disorder (SUD) observation services.

(b) Payments for observation services will be limited to a maximum of two consecutive days, except as provided in paragraph (G)(6)(c) of this rule.

(c) Payments for observation services reported with HCPCS code G0378 will be made for up to twenty-four units per day or forty-eight consecutive units (which could extend over a three-day period).

(d) Outpatient claims for observation services described in paragraph (G)(6)(a)(ii) of this rule will include:

(i) A BH/SUD primary diagnosis code; and

(ii) Modifier 'HE' at the detail level for the observation code.

(H) Coverage for acupuncture services is limited to the treatment of the services defined in rule 5160-8-51 of the Administrative Code.

Last updated January 2, 2024 at 8:53 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02, 5164.70
Five Year Review Date: 1/1/2029
Prior Effective Dates: 9/3/1991 (Emer.), 11/17/1992 (Emer.), 7/1/1994, 9/30/1994 (Emer.), 12/31/1997 (Emer.), 12/29/2000 (Emer.), 3/30/2001, 11/27/2003, 1/2/2004 (Emer.), 4/1/2004, 1/1/2005, 1/1/2014, 3/31/2014, 8/1/2017, 9/1/2018, 1/2/2020

Rule 5160-2-77 | Consumer co-payments for non-emergency emergency department services.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(A) This rule establishes a consumer co-payment for non-emergency emergency department services as authorized by section 5162.20 of the Revised Code.

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

(1) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, as defined in paragraph (B)(2) of this rule, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

(2) "Prudent lay person" means a person with an average knowledge of health and medicine to determine, within reason, that emergency services are necessary.

(3) "Non-emergency emergency department service" means an emergency department service that does not meet the definition of emergency medical condition, as defined in paragraph (B)(1) of this rule.

(C) Application of co-payment.

For dates of service on or after the effective date of this rule, medicaid consumers will pay a co-payment equal to three dollars for non-emergency emergency department services, as defined in paragraph (B)(3) of this rule, except as excluded in paragraphs (D) and (E) of this rule.

(D) Exclusions and additional limitations to the co-payment requirement for non-emergency care provided in an emergency department are in accordance with rule 5160-1-09 of the Administrative Code, except as provided in paragraph (E) of this rule.

(E) A hospital may take action to collect a co-payment as provided in section 5162.20 of the Revised Code.

(F) Reimbursement for services subject to the co-payment for non-emergency emergency department services.

The department will reimburse the emergency department claim the allowable medicaid payment, in accordance with rule 5160-2-75 of the Administrative Code, minus the applicable co-payment as described in paragraph (C) of this rule and any third party resources available to the patient, in accordance with rule 5160-2-25 of the Administrative Code.

Last updated July 1, 2021 at 10:50 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.03, 5162.20, 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 9/15/2006

Rule 5160-2-79 | Reimbursement for LARC devices.

• Effective: July 6, 2017
• Promulgated Under: 119.03

(A) Notwithstanding the provisions of rules 5160-2-65 and 5160-2-75 of the Administrative Code, long-acting reversible contraceptive (LARC) devices may be billed separately when provided during an inpatient hospitalization.

(B) LARC devices may include intrauterine devices (IUD) and subdermal contraceptive implants.

(C) Implementation and billing procedures.

(1) The provisions of this rule are effective for claims associated with the provision of a LARC device in an inpatient hospital setting on or after the effective date of this rule.

(2) Only one outpatient claim for a LARC device may be submitted for a recipient in conjunction with an inpatient obstetrical delivery claim.

(D) Payment for LARC devices.

(1) Payment for the LARC device will be made in accordance with paragraph (E) of rule 5160-4-12 of the Administrative Code, at the rate in effect on the date of service.

(2) The corresponding inpatient obstetrical delivery claim will be paid in accordance with rule 5160-2-65 of the Administrative Code.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.721
Five Year Review Date: 7/6/2022