Chapter 5160-2 Hospital Services

5160-2-01 Eligible providers.

(A) To participate in the medicaid program, a hospital must have a valid, current provider agreement. A "provider agreement" is a contractual agreement whereby the provider agrees to adhere to conditions of participation with the Ohio department of job and family services as described in rule 5101:3-1-17.2 of the Administrative Code.

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 42C.F.R 482, 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 requirements 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 facilities, and

(2) Facilities 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) The following facilities with more than sixteen beds shall be eligible to participate in Title XIX only for the provision of inpatient psychiatric services to recipients age sixty-five or older in accordance with paragraph (C) of this rule and to recipients under age twenty-one in accordance with paragraph (D) of this rule:

(1) A hospital with fifty per cent or more of its beds registered as alcohol and/or drug abuse rehabilitation beds that also has beds licensed as psychiatric beds pursuant to Chapter 5122-14 of the Administrative Code;

(2) Hospitals that have at least half of their beds licensed as psychiatric beds pursuant to Chapter 5122-14 of the Administrative Code or operated under the authority of the state mental health authority in accordance with section 5119.01 of the Revised Code; and

(3) Hospitals that have half or more of their discharges in any six-month time period reviewed by the Ohio department of job and family services and determined to be for psychiatric and/or substance abuse treatment.

(C) Hospitals that are eligible to participate only for the provision of inpatient psychiatric services in accordance with paragraph (B) of this rule and are rendering inpatient psychiatric services to recipients age sixty-five or older must be licensed by the Ohio department of mental health in accordance with Chapter 5122-14 of the Administrative Code or operated under the authority of the state mental health authority in accordance with section 5119.01 of the Revised Code, and must provide services in accordance with Chapter 5122-14 of the Administrative Code. Hospitals shall operate pursuant to the provisions of 42 C.F.R. 441 subpart C.

(D) Hospitals that are eligible to participate only for the provision of inpatient psychiatric services in accordance with paragraph (B) of this rule and are rendering inpatient psychiatric services for recipients under age twenty-one must:

(1) Provide services under the direction of a physician;

(2) Operate pursuant to the provisions of 42 C.F.R. 441 subpart D;

(3) Be a psychiatric hospital or an inpatient program in a psychiatric hospital, either of which is accredited by the "Joint Commission on Accreditation of Hospitals," and must be licensed by the Ohio department of mental health in accordance with Chapter 5122-14 of the Administrative Code or operated under the authority of the state mental health authority in accordance with section 5119.01 of the Revised Code, and must provide services in accordance with Chapter 5122-14 of the Administrative Code; and

(4) Provide services before the recipient reaches age twenty-one or, if the recipient was receiving services immediately before he/she reached age twenty-one, before the earlier of the following:

(a) The date he/she no longer requires the services; or

(b) The date he/she reaches age twenty-two.

(E) The following facilities with sixteen or fewer beds shall be eligible to participate in Title XIX only for the provision of inpatient psychiatric services to recipients in accordance with paragraph (F) of this rule:

(1) A hospital with fifty per cent or more of its beds registered as alcohol and/or drug abuse rehabilitation beds that also has beds licensed as psychiatric beds pursuant to Chapter 5122-14 of the Administrative Code;

(2) Hospitals that have at least half of their beds licensed as psychiatric beds pursuant to Chapter 5122-14 of the Administrative Code or operated under the authority of the state mental health authority in accordance with section 5119.01 of the Revised Code; and

(3) Hospitals that have half or more of their discharges in any six-month time period reviewed by the Ohio department of job and family services and determined to be for psychiatric and/or substance abuse treatment.

(F) Hospitals that are eligible to participate only for the provision of inpatient psychiatric services in accordance with paragraph (E) of this rule and are rendering inpatient psychiatric services to recipients must be licensed by the Ohio department of mental health in accordance with Chapter 5122-14 of the Administrative Code or operated under the authority of the state mental health authority in accordance with section 5119.01 of the Revised Code, and must provide services in accordance with Chapter 5122-14 of the Administrative Code. Hospitals shall operate pursuant to the provisions of 42 C.F.R. 482 subpart E.

Effective: 10/16/2006
R.C. 119.032 review dates: 08/01/2006 and 10/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 6/1/85, 10/1/87, 9/3/91 (Emer),11/10/91, 6/1/95, 8/1/02

5160-2-02 General provisions: hospital services.

(A) The Ohio medicaid program provides payment for medically necessary covered inpatient and outpatient services provided to eligible medicaid recipients by an eligible hospital provider as defined in rule 5101:3-2-01 of the Administrative Code, subject to the provisions of this chapter and Chapter 5101:3-1 of the Administrative Code(relating to general provisions).

(B) The following words and terms, when used in this chapter have the following meanings, unless the context clearly indicates otherwise:

(1) "Inpatient" - A patient who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient stay continues beyond midnight of the day of admission.

(2) "Inpatient services" - Services which are ordinarily furnished in a hospital as defined in rule 5101:3-2-01 of the Administrative Code for the care and treatment of inpatients. Inpatient services include all covered services provided to patients during the course of their inpatient stay, whether furnished directly by the hospital or under arrangement, except for direct-care services provided by physicians, podiatrists, and dentists. Inpatient hospital services exclude direct-care physician services except as provided in rule 5101:3-4-01 of the Administrative Code. Emergency room services are covered as an inpatient service when a patient is admitted from the emergency room.

(3) "Outpatient" - A patient who is not an inpatient as defined in paragraph (B)(1) of this rule and who receives outpatient services at a hospital or at a hospital's off-site unit which has been extended accreditation by the "Joint Commission of Accreditation of Health Care Organizations," the "American Osteopathic Association" and/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 another inpatient unit within the hospital, to another hospital, or to a state psychiatric facility.

(4) "Outpatient services" - Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital as defined in rule 5101:3-2-01 of the Administrative Code. Outpatient services do not include direct-care services provided by physicians, podiatrists and dentists. Outpatient services exclude direct-care physician services except as provided in rule 5101:3-4-01 of the Administrative Code.

(5) "Diagnostic related groups (DRGs)" - DRGs are a patient classification system that reflects clinically cohesive groupings of services that consume similar amounts of hospital resources. The grouping logic used to develop relative weights is described in rule 5101:3-2-07.3 of the Administrative Code. The groupings used to assign cases to a DRG for claims payment are identified in rule 5101:3-2-07.11 of the Administrative Code.

(6) "Average" is the arithmetic mean obtained by dividing a sum by the number of its observations.

(7) "Geometric mean" is the nth root of the product of n factors.

(8) "Psychiatric unit distinct part" is a distinct part recognized by medicare.

(9) "Level I nursery" is a nursery unit within a hospital which is registered with and recognized by the Ohio department of health as a level I nursery.

(10) "Level II nursery" is a nursery unit within a hospital which is registered with and recognized by the Ohio department of health as a level II nursery.

(11) "Level III nursery" is a nursery unit within a hospital that is registered with and recognized by the Ohio department of health as a level III nursery.

(12) "Standard deviation" is the square root of the arithmetic mean of the squares of the deviations from the arithmetic mean.

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

(14) "Medically necessary services" are services which are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part or significant pain and discomfort. A medically necessary service must:

(a) Meet accepted standards of medical practice;

(b) Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome;

(c) Be appropriate to the intensity of service and level of setting;

(d) Provide unique, essential, and appropriate information when used for diagnostic purposes.

(15) Transfer.

A patient is said to be "transferred" when he or she:

(a) Is moved from one eligible hospital, as described in rule 5101:3-2-01 of the Administrative Code, to another eligible hospital, including state psychiatric facilities.

(b) Is moved from an eligible hospital to the same hospital's psychiatric unit distinct part.

(c) Is moved to an eligible hospital from the same hospital's psychiatric unit distinct part.

(16) Readmissions.

For hospitals paid under the department's prospective payment system, a "readmission" is an admission to the same institution within thirty days of discharge.

(17) Discharges.

A patient is said to be "discharged" when he or she:

(a) Is formally released from a hospital;

(b) Dies while hospitalized;

(c) Is discharged, within the same hospital, from an acute care bed and admitted to a bed in a psychiatric unit distinct part as described in paragraph (B)(8) of this rule or is discharged within the same hospital, from a bed in a psychiatric unit distinct part to an acute care bed. Rule 5101:3-2-07.11 of the Administrative Code explains the payment methodology for this type of a discharge; or

(d) Signs himself or herself out against medical advice (AMA).

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

(C) Billing: All inpatient and outpatient hospital services must be billed in accordance with national uniform billing requirements for hospital facilities (available on http://www.nubc.org/). Appendix A to this rule describes revenue codes that are covered under the medicaid hospital benefit.

Click to view Appendix

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Effective: 12/06/2010
R.C. 119.032 review dates: 09/20/2010 and 12/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80, 10/1/83
(Emer), 12/29/83, 10/1/84, 11/9/84 (Emer), 2/4/85, 7/29/85, 7/3/86, 10/19/87, 4/23/88, 7/1/89, 12/1/89, 7/1/90, 9/3/91 (Emer), 11/10/91, 7/1/92, 7/1/93, 1/20/95, 12/29/95 (Emer), 3/16/96, 8/1/02, 10/1/03, 6/1/04, 10/1/05

5160-2-03 Conditions and limitations.

(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 5101:3-4-01 of the Administrative Code.

(2) Inpatient or outpatient services related to the provision of the services described in paragraphs (A)(2)(a) to (A)(2)(i) of this rule are not covered:

(a) Abortions other than those that meet the criteria for coverage set forth in rule 5101:3-17-01 of the Administrative Code.

(b) Sterilizations and hysterectomies other than those that meet the criteria for coverage set forth in rule 5101:3-21-01 of the Administrative Code.

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

(d) Treatment of obesity, including but not limited to gastroplasty, gastric stapling, ileo-jejunal shunt, or other gastric restrictive procedures.

(e) 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.

(f) Acupuncture.

(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 nonhospital 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, or precertified as an inpatient admission as described in rule 5101:3-2-40 of the Administrative Code.

(i) Patient convenience items, including television service.

(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 room will be covered only when such accommodations are medically necessary and the patient's condition requires the patient to be isolated for the patient's own health or the health of others.

(2) Covered days: In general, medicaid covers only those days of care that are medically necessary or otherwise within certain limits. The provisions set forth in this paragraph operate as limitations in one of two ways. The number of days of care charged by a hospital must be in units of full days. The day of admission counts as a full day. 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 to 0179 (see rule 5101:3-2-02 of the Administrative Code for identification of revenue center codes) are covered. Charges for the services described in the foregoing sentence are covered on the days the services were rendered;, not the day the charges were posted. For hospitals identified in rule 5101:3-2-07.1 of the Administrative Code that are paid on a prospective basis, the noncovered days of inpatient stay described in paragraphs (B)(2)(a) to (B)(2)(f) of this rule will be excluded for purposes of determining outliers in accordance with rule 5101:3-2-07.9 of the Administrative Code. For hospitals excluded from the prospective payment system as identified in rule 5101:3-2-07.1 of the Administrative Code, the noncovered days of inpatient stay described in paragraphs (B)(2)(a) to (B)(2)(f) of this rule, including associated inpatient services, are not covered and, accordingly, are not reimbursable.

(a) Rehabilitation services related to chemical dependencies: Coverage of inpatient days for treatment of a chemical dependency is limited to coverage of services for detoxification. No coverage is available for days of inpatient care that occur solely for the provision of rehabilitation services related to a chemical dependency.

(b) Benefit period--The number of days of inpatient care covered under the medicaid program shall not exceed thirty days during a period beginning on the day of the recipient's admission to a hospital and ending sixty days after the termination of that hospital stay, whether or not completed in the same hospital. However, the department will make exceptions to this limitation, when:

(i) The recipient is jointly eligible under the medicaid program and the program for medically handicapped children as described in section 3701.023 of the Revised Code.

(ii) Additional hospitalization is medically necessary before sixty days have passed since the most recent discharge date.

(iii) A determination is made by the hospital that the care was medically necessary in accordance with rule 5101:3-2-07.13 of the Administrative Code.

(iv) The hospital is paid on a prospective diagnosis related group (DRG) basis.

(v) The hospital is recognized as a long-term care hospital under medicare.

(c) 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 and/or physician's negligence.

(d) 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.

(e) Days waiting for placement and custodial care--Coverage is not available for hospital inpatient services for patients who no longer require acute short-term hospital care. 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.

(f) Psychiatric admissions to hospitals not licensed by the department of mental health--Admissions of persons whose principal diagnosis is a mental disorder as described in Chapter 5122-14 of the Administrative Code into hospitals not licensed by the department of mental health will not be reimbursed by the medicaid program.

(C) Coverage conditions and limitations applicable to outpatient services only.

(1) When recipients use greater than forty-eight outpatient visits per year, information from paid claims will be reviewed by the department to determine whether the recipient should be referred to a managed care program. As a result of this review, the department or its contractual designee may also review hospital medical records in accordance with rule 5101:3-2-07.13 of the Administrative Code to determine whether services were medically necessary and appropriate to the recipient's illness or injury as described in rule 5101:3-2-02 of the Administrative Code.

(2) For purposes of paragraph (C)(1) of this rule, a visit is defined as services provided on one date of service to one recipient.

(D) Coverage conditions and limitations applicable to hospitals eligible to provide services pursuant to paragraphs (C) , (D) and (F) of rule 5101:3-2-01 of the Administrative Code.

(1) Coverage of inpatient services provided in hospitals to eligible recipients shall be provided in accordance with Chapter 5122-14 of the Administrative Code or section 5119.20 of the Revised Code.

(2) Outpatient services provided in hospitals to eligible recipients are not coverable under the provisions set forth in Chapter 5101:3-2 of the Administrative Code.

Effective: 04/01/2009
R.C. 119.032 review dates: 01/13/2009 and 04/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80, 7/1/82, 10/1/83 (Emer), 12/29/83, 10/1/84, 7/3/86, 11/1/86, 4/6/88 (Emer), 6/24/88, 7/1/90, 7/1/92, 6/1/95, 8/1/02, 10/1/03

5160-2-04 Coverage of hospital provided pharmaceutical, dental, vision care, medical supply and equipment, and ambulance or ambulette services.

(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 5101:3-2-21 of the Administrative Code. Take-home drugs must be billed in accordance with provisions in Chapter 5101:3-9 of the Administrative Code. Payment to hospitals for take-home drugs will be reimbursed according to the provisions of Chapter 5101:3-9 of the Administrative Code. ODJFS may periodically require hospitals to produce evidence of invoice costs supporting amounts billed for take-home drugs.

(B) Medical supplies and equipment.

(1) Inpatient: Supplies and equipment for the care and treatment of the recipient during an inpatient stay, including implants and devices that are part of a surgical, immediate post surgical, or early fitting procedure (e.g., pacemakers, halos, and prosthetic devices), appliances that are generally applied prior to discharge (e.g., initial prostheses), and other items that are medically necessary as described in rule 5101:3-2-02 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 are covered inpatient hospital services and, as such, must be included in the hospital's inpatient billing. In order to be reimbursed for supplies and equipment furnished to an inpatient for use solely outside the hospital, the hospital must be approved under the medicaid program as a medical supplies provider. See Chapter 5101:3-10 of the Administrative Code for coverage, limitation, billing, and reimbursement provisions relative to medical supplies providers.

(2) Outpatient: In order to be reimbursed for medical supplies and equipment on an outpatient basis, a hospital must be approved under the medicaid program as a medical supplies provider. Hospital outpatient departments that so desire may make application to provider enrollment. See Chapter 5101:3-10 of the Administrative Code for coverage, limitation, billing, and reimbursement provisions relative to medical supplies providers.

(C) Dental services: Except for dental services described in rule 5101:3-2-03 of the Administrative Code and emergency dental services provided in the emergency room, all outpatient dental services are covered and reimbursed as dental services under the provisions set forth in Chapter 5101:3-5 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 5101:3-6 of the Administrative Code.

(E) Ambulance and ambulette services: The services of hospital staff as attendents during transportation are covered and reimbursed as an inpatient or outpatient hospital service. Services related to the use and operation of the transport vehicle, including standard equipment and driver, are reimbursed as an ambulance or ambulette service. The provisions of this paragraph apply to ambulance and ambulette services provided to or from the hospital, including interhospital ambulance or ambulette services. See Chapter 5101:3-15 of the Administrative Code for coverage, limitation, billing, and reimbursement provisions relative to ambulance and ambulette services providers.

Effective: 11/01/2007
R.C. 119.032 review dates: 08/15/2007 and 11/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80, 10/1/83 (Emer), 12/29/83, 10/1/84, 9/3/91 (Emer), 11/10/91, 8/1/02

5160-2-07.1 Hospital services subject to and excluded from DRG prospective payment.

All inpatient services associated with admissions occurring on and after October 1, 1984, and furnished by hospitals defined as eligible providers of hospital services in rule 5101:3-2-01 of the Administrative Code, are subject to the DRG prospective payment system described in this chapter except for services described in paragraphs (A) and (B) of this rule.

(A) Services provided by the following institutions:

(1) "Freestanding rehabilitation hospitals" which the department of health and human services has determined to be excluded from medicare prospective payment in accordance with 42 CFR 412.23(b) effective October 1,2003;

(2) "Freestanding long-term hospitals" which the department of health and human services has determined to be excluded from medicare prospective payment in accordance with 42 CFR 412.23(e) effective October 1, 2003;

(3) Hospitals that are excluded from medicare prospective payment due to providing services, in total, which are excluded due to a combination of the provisions of paragraphs (A)(1) and (A)(2) of this rule;

(4) Ohio hospitals which are owned and operated by health insuring corporations licensed by the Ohio department of insurance and which limit services to medicaid recipients (either to recipients enrolled in a health insuring corporation or to short-term services provided on an emergency basis).

(5) Cancer hospitals as defined in rule 5101:3-2-07.2 of the Administrative Code for discharges on and after July 1, 1992.

(B) Transplant services are subject to the DRG prospective payment system with the

following exceptions, as listed in paragraphs (B)(1) to (B)(3) of this rule.

(1) Heart/lung and pancreas transplantation services provided by eligible medicaid providers to eligible medicaid recipients;

(2) Single/double lung transplantation services by eligible medicaid providers to eligible medicaid recipients who are discharged on or after January 1, 1991 and prior to February 1, 2000.

(3) Liver/small bowel transplantation services for eligible medicaid providers to eligible medicaid recipients.

(4) 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 the department's prior authorization unit.

(5) Reimbursement for bone marrow transplant and hematapoietic stem cell transplant, as defined in rule 3701-84-01 of the Administrative Code, 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 the department's prior authorization unit. Authorization is contingent upon the transplant program's approval by the Ohio department of health or a letter of nonreview ability from the Ohio department of health, or having had a bone marrow transplant program in operation prior to April 2, 1992. Reimbursement is further contingent upon:

(a) Membership in the "Ohio Hematopoietic Stem Cell Transplant Consortium"; or

(b) Compliance with the performance standards described in rules 3701-84-24 to 3701-84-29 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.

Eff 10-1-84; 7-29-85; 7-3-86; 10-19-87; 7-1-89; 1-1-91; 9-3-91 (Emer.); 11-10-91; 7-1-92; 4-1-93; 8-1-93; 2-1-00; 8-1-02; 6-1-04
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01 , 5111.02
R.C. 119.032 review dates: 03/12/2004 and 06/01/2009

5160-2-07.2 Classification of hospitals.

For purposes of setting rates and making payments under the "Diagnosis Related Group" (DRG) prospective payment system, the department classifies most hospitals into mutually exclusive peer groups.

(A) Definitions.

(1) "Teaching hospitals" are hospitals with major teaching emphasis that meet one of the following definitions: the hospital, regardless of number of beds has an intern- and resident-to-bed ratio of at least .35 or the hospital has greater than five hundred beds and has an intern- and resident-to-bed ratio of .25. For purposes of this paragraph, the intern- and resident-to-bed ratio for Ohio hospitals is that recognized by the hospital's medicare fiscal intermediary for the hospital's cost-reporting period described in paragraph (D) of rule 5101:3-2-07.4 of the Administrative Code. For non-Ohio hospitals, the internand resident-to-bed ratio used to make this determination is derived from the medicare cost report for the cost-reporting period used in setting rates for rate period beginning July 1, 1990.

(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, 2006.

(3) "Rural referral center hospitals" are those hospitals located in non-metropolitan statistical areas (MSAs) that are recognized by medicare as rural referral centers in accordance with 42 C.F.R. 412.96 effective October 1, 2006.

(4) "MSA hospitals" are those hospitals not defined in this rule as children's or teaching hospitals that are located in MSAs as those areas are established by the federal office of management and budget.

(5) "Non-MSA hospitals" are those hospitals not defined in this rule as teaching, children's, or rural referral centers that are not located in MSAs as those areas are established by the federal office of management and budget.

(6) "Cancer hospitals" are hospitals recognized by medicare that primarily treat neoplastic disease in accordance with 42 C.F.R. 412.23(f) effective October 1, 2006.

(7) For the purposes of this rule, the "number of beds" is the total number of beds reported in the December, 1986 "Directory of Registered Hospitals" published by the Ohio department of health.

(B) Ohio hospital prospective payment peer groups.

(1) For each Ohio children's hospital, a prospective rate will be determined in accordance with rule 5101:3-2-07.4 of the Administrative Code using data specific to each hospital.

(2) Rural referral center hospitals are grouped together and a peer group average cost per discharge is developed in accordance with rule 5101:3-2-07.4 of the Administrative Code using data from these hospitals.

(3) Teaching hospitals are grouped together and a peer group average cost per discharge is developed in accordance with rule 5101:3-2-07.4 of the Administrative Code using data from these hospitals.

(4) Non-MSA hospitals with less than one hundred beds are grouped together and a peer group average cost per discharge is developed in accordance with rule 5101:3-2-07.4 of the Administrative Code using data from these hospitals.

(5) Non-MSA hospitals with one hundred beds or more are grouped together and a peer group average cost per discharge is developed in accordance with rule 5101:3-2-07.4 of the Administrative Code using data from these hospitals.

(6) MSA hospitals are peer grouped on the basis of wage index categories. MSA hospitals that have adjusted gross wage index categories in their area, as published in the March 1985 "Report on Hospital Wage Index" required by section 2316(a) of Public Law 98-369 within .01 (rounded values) of each other are grouped together for payment purposes. For each of the groups formed, a peer group average cost per discharge is developed in accordance with rule 5101:3-2-07.4 of the Administrative Code using data from hospitals in the group.

(C) Non-Ohio prospective payment peer groups.

(1) For discharges on or after July 1, 1990, non-Ohio teaching hospitals will be reimbursed on the basis of a rate developed using data from Ohio teaching hospitals. The calculations used to develop this rate are described in paragraphs (C)(1)(a) to (C)(1)(b) of this rule.

(a) For each Ohio teaching hospital a fully adjusted, inflated peer group average cost per discharge is calculated as described in paragraphs (D) to (G)(3)(a) of rule 5101:3-2-07.4 of the Administrative Code except that the adjustment described in paragraphs (D)(9) to (D)(9)(b) of rule 5101:3-2-07.4 of the Administrative Code is not made.

(b) The fully adjusted, inflated peer group average cost per discharge described in paragraph (C)(1)(a) of this rule is multiplied by each hospital's medicaid discharges as described in paragraph (D)(11)(a) of rule 5101:3-2-07.4 of the Administrative Code. The results of these computations are summed for all Ohio teaching hospitals, and then divided by the sum of medicaid discharges for all Ohio teaching hospitals. The result of this computation is rounded to the nearest whole penny.

(2) For discharges on or after July 1, 1990, non-Ohio children's hospitals will be reimbursed on the basis of a rate developed using data from Ohio childrens hospitals. The calculations used to develop this rate are described in paragraphs (C)(2)(a) to (C)(2)(b) of this rule.

(a) For each Ohio children's hospital a fully adjusted, inflated peer group average cost per discharge is calculated as described in paragraphs (D) to (G)(3)(b) of rule 5101:3-2-07.4 of the Administrative Code except that the adjustment described in paragraphs (D)(9) to (D)(9)(b) of rule 5101:3-2-07.4 of the Administrative Code is not made and except that the value of .12 is substituted for the value calculated in paragraph (F)(2)(e)(ii) of rule 5101:3-2-07.4 of the Administrative Code.

(b) The fully adjusted, inflated peer group average cost per discharge described in paragraph (C)(2)(a) of this rule is multiplied by each hospital's medicaid discharges as described in paragraph (D)(11)(a) of rule 5101:3-2-07.4 of the Administrative Code. The results of these computations are summed for all Ohio children's hospitals, and then divided by the sum of medicaid discharges for all Ohio children's hospitals. The result of this computation is rounded to the nearest whole penny.

(3) For discharges on or after July 1, 1990, non-Ohio hospitals that are not teaching or children's hospitals will be reimbursed on the basis of a rate developed using data from Ohio nonteaching and nonchildren's hospitals. The calculations used to develop this rate are described in paragraphs (C)(3)(a) to (C)(3)(b) of this rule.

(a) For each Ohio nonchildren's and nonteaching hospital, a fully adjusted, inflated peer group average cost per discharge is calculated as described in paragraphs (D) to (G)(3)(a) of rule 5101:3-2-07.4 of the Administrative Code except that the adjustment described in paragraphs (D)(9) to (D)(9)(b) of rule 5101:3-2-07.4 of the Administrative Code is not made.

(b) The fully adjusted, inflated peer group average cost per discharge described in paragraph (C)(3)(a) of this rule is multiplied by each hospital's medicaid discharges as described in paragraph (D)(11)(a) of rule 5101:3-2-07.4 of the Administrative Code. The results of these computations are summed for all Ohio nonteaching and nonchildrens hospitals, and then divided by the sum of medicaid discharges for all Ohio nonteaching and nonchildrens hospitals. The result of this computation is rounded to the nearest whole penny.

(D) Classification procedures.

(1) A hospital is classified into a peer group at the beginning of each rate year based upon the data available to the department sixty days prior to the rate year. Once established, the classification of a hospital into a peer group remains in effect throughout the rate year unless the hospital is designated by medicare during the rate year to be a rural referral center hospital. In this instance the hospital must submit all documentation to the department that it has been designated as a rural referral center. After such documentation is received, the hospital will be reclassified into the rural referral center peer group effective for discharges occurring on or after the beginning of the rate year or the effective date of the designation, whichever is later.

(2) When an existing hospital is deleted or added to a peer group at a time other than when the department rebases the DRG system, the deletion or addition of a hospital from a peer group does not result in a redetermination of payment rates for the peer group except as otherwise provided in rule 5101:3-2-07.8 of the Administrative Code. If a new hospital is established at a time other than when the department rebases the DRG system, the department will assign that hospital to a peer group for payment purposes but will not recalculate any part of the prospective payment rate for that peer group.

(3) Facilities that close at a time other than rebasing of the DRG system and that notify the department of closure thirty days prior to the beginning of a rate year are not included in the peer groups defined in this rule for the purpose of setting payment rates. Closure notifications received less than thirty days prior to a rate year do not result in a redetermination of peer group payment rates for that year.

(4) In the case of hospital mergers when all facilities involved in the merger retain separate provider numbers for the medicare program, each facility will be treated separately following the procedures outlined in this rule. In the case of hospital mergers when the merged facility retains only one medicare provider number, the department will either follow the determinations made by the medicare program with regard to treatment of the merged facilities or will make a separate determination. Such separate determinations will be made, on a case by case basis, in instances when medicare's determination would be appropriate in the context of medicare pricing and classification methods but inappropriate in the context of medicaid pricing methods and peer grouping logic as described in this rule.

Effective: 12/22/2007
R.C. 119.032 review dates: 09/26/2007 and 12/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 10/4/84, 7/29/85, 7/3/86, 10/19/87, 7/1/90, 9/3/91 (Emer), 11/10/91, 7/1/92, 8/1/02

5160-2-07.3 Methodology for determining relative weights.

(A) General description.

For hospitals subject to prospective payment for inpatient services, the Ohio department of job and family services, ("ODJFS") will reimburse for inpatient hospital services an amount per discharge in each diagnostic category. The payment is reflective of the relative hospital resources used by each diagnostic category in comparison to the statewide average resource use for an admission. The method for determining the weight of a diagnostic category is based on its average charge compared to an average charge for all discharges. This rule describes the diagnostic categories and the method for determining the relative weights for each category. Special consideration is given to psychiatric diagnostic related groups (DRGs) 425 to 435 and neonatal DRGs 385 to 390 as described in this rule.

(B) Diagnostic related groupings.

(1) Except as otherwise specified in paragraph (E) of this rule, relative weights are calculated for each classification of inpatient hospital discharge classified by "grouper," a software package distributed by, "3M Health Information Systems,"" used by medicare during federal fiscal year 1998, and modified as described in this rule. Services are classified into one of the diagnostic categories based on:

(a) The "International Classification of Diseases, 9th Revision, Clinical Modification" (ICD-9-CM), principal and secondary diagnoses;

(b) The ICD-9-CM surgical procedures provided to the recipient during a hospital stay;

(c) The recipient's sex;

(d) The recipient's age; and

(e) The recipient's discharge status.

(2) Cases that would be classified in DRG 385 or DRG 456 because of a transfer or death but hat involve a length of stay greater than fifteen days are classified in the DRG that is appropriate in accordance with paragraphs (B)(1) to (B)(1)(e) of this rule if the transfer or death is not considered.

(3) For cases classified into DRG 386, three subgroups are identified and three different relative weights are calculated, based upon the ICD-9-CM codes and the level of the neonatal nursery. These levels are those recognized by the Ohio department of health as of March 29, 1987.

(a) One subgroup and relative weight is created based upon cases tha

have ICD-9-CM code 765.0 listed as one of its diagnoses.

(b) For cases tha group as a DRG 386, and do not have ICD-9-CM code 765.0, two relative weights are calculated for this subgroup. One relative weight is calculated using data specific to hospitals with a level I or II nursery and a second relative weight is calculated using data specific to hospitals with a level III nursery.

(4) For cases classified into DRG 387, four subgroups are identified and four different relative weights are calculated, based upon the infant's birthweight and the level of the neonatal nursery. These levels are those identified by the Ohio department of health as of March 29, 1987. These subgroups are described in paragraphs (B)(4)(a) and (B)(4)(b) ofthis rule.

(a) For cases that group into DRG 387 and have a birthweight of zero to one thousand seven hundred fifty grams, two subgroups are identified and two relative weights are calculated within each subgroup. One relative weight is calculated using data specific to hospitals with a level I or II nursery and a second relative weight is calculated using data specific to hospitals with a level III nursery.

(b) For cases tha group into DRG 387 and have a birthweight of one thousand seven hundred fifty-one grams and above, two subgroups are identified and two relative weights are calculated within each subgroup. One relative weight is calculated using data specific to hospitals with a level I or II nursery and a second relative weight is calculated using data specific to hospitals with a level III nursery.

(C) Medicaid claim record.

For the purposes of determining the relative weight for each DRG, the sample includes all claims associated with discharges, as described in paragraphs (C)(1) and (C)(2) of this rule.

(1) Effective for discharges on January 1, 2006 through -34, £009December 31, 2011: For the purposes of determining the relative weight for each DRG, the sample includes all claims associated with discharges on or after July 1, 2001 through June 30, 2003 and paid by December 31, 2003.

All claims included in the sample were previously paid and passed through the edits created by ODJFS's prospective payment system. Claims were adjusted as described in paragraphs (C)(3) to (C)(4)(b) of this rule.

(2) Effective for discharges on or after January 1, 2012, and every calendar year thereafter, relative weights shall be determined on an annual basis. For the purposes of determining the relative weight for each DRG, the sample includes all claims associated with discharges during 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 relative weights shall apply. All claims included in the sample were previously paid and passed through the edits created by ODJFS's prospective payment system. Claims were adjusted as described in paragraphs (C)(3) to (C)(4)(b) of this rule.

(3) Claims deleted from computation.

(a) Claims that were submitted by an out-of-state provider.

(b) Claims that were submitted by hospitals excluded from the prospective payment system as described in rule 5101:3-2-07.1 of the Administrative Code.

(c) Claims that were originally grouped into DRG 000, 469 or 470.

(d) When two or more records existed with the same provider, same recipient number, and exact dates of services, the latest paid claim was retained and the earlier paid claim or claims were deleted.

(e) If multiple claims for the same provider, same recipient number, and overlapping dates of service occurred, and the date span of the most recently paid claim included the date span of any and all overlap claims, and none of the claims grouped into DRGs 425 to 435, the most recently paid claim was retained and all others were deleted.

(f) Claims associated with cases that were incorrectly billed to ODJFS, e.g., where third party covered the entire stay.

(g) Claims that were for an inpatient discharge but had charges of less than one hundred dollars, unless there were ten or fewer claims that grouped into the DRG.

(h) Transfer claims unless there were ten or fewer claims that grouped into the DRG.

(i) Nontransfer claims paid on a per diem basis. (j) Claims with net charges equal to zero.

(4) Adjustments to claims.

(a) Claim-specific adjustments were included if processed by

ODJFS on or before the last day of the medicaid claim record period as described in paragraphs (C)(1) and (C)(2) of this rule.

(b) Organ acquisition and transportation costs for heart, liver, and bone marrow transplants were removed from the claim prior to submission to the grouper.

(D) Development ofthe relative weights.

The relative weights were calculated based upon the total allowable charge for each case for the sample of claims as described in paragraphs (C) to (C)(4)(b) of this rule, subject to the edits as described in paragraphs (D)(3)(a) and (D)(3)(b) of this rule.

(1) Computation of the geometric mean charge for each DRG.

(a) For DRGs 1 to 385, 391 to 424, and 439 to 503, the geometric mean charge was determined for each ofthese DRGs.

(b) For each subgroup in DRG 386 as described in paragraphs (B)(3) to (B)(3)(b) of this rule, and for each subgroup of DRG 387 as described in paragraphs (B)(4) to (B)(4)(b) of this rule, the geometric mean charge was calculated.

(c) For DRGs 388, 389, and 390, the geometric mean charge was calculated three times to determine a geometric mean charge specific to hospitals with a level I nursery, hospitals with a level II nursery, and hospitals with a level III nursery. For example, three geometric mean charges were calculated for DRG 388, one reflecting data from hospitals with a level I nursery; one reflecting data from hospitals with a level II nursery; and one reflecting data from hospitals with a level III nursery.

(d) For DRGs 425 to 435, two geometric mean charges were calculated for each DRG in this category. One geometric mean charge was calculated using the charge for each case within these DRGs from free-standing psychiatric hospitals, and hospitals that have a psychiatric unit distinct part. A "psychiatric unit distinct part" is one hat is recognized by medicare as described in rule 5101:3-2-02 of the Administrative Code and where the hospital has notified the ODJFS of medicare's certification. A second geometric mean charge was calculated for each DRG 425 to 435 using data from all other hospitals (hospitals hat do not have a recognized psychiatric unit distinct part under medicare). In accordance with rule 5101:3-2-03 of the Administrative Code,ODJFS does not pay for DRG 436 and DRG 437.

(e) If no cases were grouped by the medicare fiscal year 1998 grouper into any DRG, the geometric mean charge for these DRGs is the geometric mean charge that was used for these DRGs prior to the effective date of this rule.

(2) Calculation of the statewide geometric mean length of stay for each DRG.

(a) For DRGs 1 to 385, 391 to 424, and 439 to 503, the geometric mean length of stay was calculated using all cases within each of these DRGs as determined in paragraph (C) of this rule.

(b) For each subgroup in DRG 386 as described in paragraphs (B)(3) to (B)(3)(b) of this rule and for each subgroup of DRG 387 as described in paragraphs (B)(4) to (B)(4)(b) of this rule, the geometric mean length of stay was calculated.

(c) For DRGs 388, 389, and 390, the geometric mean length of stay was calculated three times to determine geometric mean length of stay specific to hospitals with a level I nursery, hospitals with a level II nursery, and hospitals with a level III nursery. For example, three geometric mean lengths of stay were calculated for DRG 388; one geometric mean length of stay was calculated using all cases in DRG 388 within a hospital hat has a level I nursery; one geometric mean length of stay was calculated based on data from hospitals with a level II nursery; and one geometric mean length of stay was calculated based on data from hospitals with a level III nursery.

(d) For DRGs 425 to 435, the geometric mean length of stay was calculated two times for each of these DRGs to reflect the difference in the geometric mean length of stay in hospitals with and without psychiatric unit distinct parts. To determine the geometric mean length of stay for cases treated in hospitals with no distinct part psychiatric unit, the geometric mean length of stay was calculated using all cases in these hospitals. To determine the geometric mean length of stay for cases in hospitals with psychiatric unit distinct parts, the geometric mean length of stay was calculated using all cases in these hospitals.

(e) If no cases were grouped by the medicare fiscal year 1998 grouper into any DRG, the geometric mean length of stay for these DRGs is the geometric mean length of stay that was used for these DRGs prior to the effective date of this rule.

(3) Deletion of outlier cases.

(a) For each DRG and each subgroup within DRGs 386 to 390 and 425 to 435, a standard deviation for charge and length of stay was calculated based upon the cases used in the calculation of the geometric mean as described in paragraphs (D)(1) to (D)(2)(d) of this rule.

(b) Cases hat had charges or reflected a length of stay that was two standard deviations above the geometric mean as calculated in paragraphs (D)(1) to (D)(2)(d) of this rule were deleted except for DRGs 385 to 390. For DRGs 385 to 390 cases that had charges or reflected a length of stay that is one standard deviation above the geometric mean as calculated in paragraphs (D)(1) to (D)(2)(d) of this rule were deleted.

(4) Recalculation of geometric mean length of stay and geometric mean charge for each DRG and subgroups in DRGs 386 to 390 and 425 to 435 was done excluding outlier cases as described in paragraphs (D)(3)(a) and (D)(3)(b) of this rule.

(5) Computation of the arithmetic mean charge for each DRG.

Computation of the arithmetic mean charge for each DRG and subgroups was calculated using all cases as described in paragraphs (C)(1) to (C)(4)(b) of this rule, excluding outlier cases, as described in paragraphs (D)(3)(a) and (D)(3)(b) of this rule.

(a) For DRGs 1 to 385, 391 to 424, and 439 to 503, the arithmetic mean charge was determined for each of these DRGs using the total charge per case for each DRG for all hospitals excluding outlier cases.

(b) For each subgroup in DRG 386 as described in paragraphs (B)(3) to (B)(3)(b) of this rule, and for each subgroup of DRG 387 as described in paragraphs (B)(4) to (B)(4)(b) of this rule, the arithmetic mean charge was determined excluding outlier cases.

(c) For DRGs 388, 389, and 390, three separate arithmetic means were calculated for each DRG using data specific to either hospitals with a level I nursery, with a level II nursery, or hospitals with a level III nursery unit. In each instance, the claims used within a DRG, and within a specific level nursery, excluded outlier cases.

(d) For DRGs 425 to 435, two arithmetic mean charges were calculated for each DRG in this category. One arithmetic mean charge was calculated using the total charge for each case within these DRGs, excluding outlier cases, from hospitals that had a psychiatric unit distinct part. A second arithmetic mean charge was calculated for DRGs 425 to 435 using data, excluding outlier cases, from all other hospitals (hospitals hat did not have a recognized psychiatric unit distinct part under medicare).

(e) If no cases were grouped by the medicare fiscal year 1998 grouper into any DRG, the arithmetic mean charge for these DRGs is the arithmetic mean charge that was used for these DRGs prior to the effective date of this rule.

(6) Calculation of the statewide arithmetic mean charge per discharge.

The statewide arithmetic mean charge per discharge was calculated using the total allowable charge for all cases used in the calculation described in paragraphs (D)(5) to (D)(5)(d) of this rule.

(7) Computation of the relative weight for each DRG and DRG subgroups.

The relative weight of each DRG is a function of the relationship between the arithmetic mean charge per DRG and DRG subgroups and the arithmetic mean charge across all cases. To determine the relative weight, the arithmetic mean charge for each DRG and DRG subgroup calculated as described in paragraphs (D)(5)(a) to (D)(5)(d) of this rule was divided by the statewide arithmetic mean charge per discharge as described in paragraph (D)(6) of this rule.

(E) Relative weights for small cell DRGs.

When ten or less claims grouped into a DRG, ODJFS established relative weights taking into consideration the weights that previously were used for the DRG, as well as the DRG case mix. When ten or less claims grouped into a new DRG, ODJFS used relative weights currently used by medicare.

Effective: 01/01/2010
R.C. 119.032 review dates: 10/13/2009 and 01/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02 , Section 309.30.18 of Am. Sub. H.B. 1, 128th
G.A.
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , Section 309.30.18 of
Am. Sub. H.B. 1, 128th G.A. Prior Effective Dates: 10/4/84, 7/3/86, 10/19/87, 9/3/91 (Emer), 11/10/91,
1/20/95, 1/1/98, 2/1/00, 10/13/05, 3/12/07, 7/24/08

5160-2-07.4 Basic methodology for determining prospective payment rates.

(A) General description.

Except as provided in paragraph (B) of this rule, in computing the payment rate, the average cost per discharge determined and adjusted as described in paragraphs (D) to (G)(3)(b) of this rule is multiplied by the relative weight as described in rule 5101:3-2-07.3 of the Administrative Code for the diagnosis related group(DRG) as defined in rule 5101:3-2-02 of the Administrative Code. Applicable allowances for capital and medical education, as described in this rule, are added after the average cost per discharge component is multiplied by the relative weight. The components of the prospective payment rates for each recipient discharged from a hospital are:

(1) The DRG assigned to that discharge;

(2) The adjusted inflated average cost per discharge component described in paragraphs (D) to (G)(3)(b) of this rule;

(3) Relative weights defined in rule 5101:3-2-07.3 of the Administrative Code for each DRG;

(4) An allowance for capital described in rule 5101:3-2-07.6 of the Administrative Code; and

(5) For certain hospitals, a medical education allowance as described in rule 5101:3-2-07.7 of the Administrative Code.

(B) Payment rates.

Payment rates consist of the components described in paragraphs (A) to (A)(5) of this rule, subject to special payment provisions for certain types of cases, as described in rules 5101:3-2-07.9 and 5101:3-2-07.11 of the Administrative Code.

(C) Determination of average cost per discharge component.

(1) For children's hospitals as defined in rule 5101:3-2-07.2 of the Administrative Code, the average cost per discharge component is one hundred per cent hospital specific and is determined in accordance with paragraphs (D) to (G)(3)(b) of this rule.

(2) For out-of-state hospitals for discharges on or after July 1, 1990, the average cost per discharge component is determined in accordance with the methodology described in paragraphs (C)(1) to (C)(3)(b) of rule 5101:3-2-07.2 of the Administrative Code.

(3) For hospitals other than those identified in paragraphs (C)(1) and (C)(2) of this rule, the average cost per discharge component will be one hundred per cent of the peer group average costs per discharge determined in accordance with paragraphs (E) to (G)(3)(a) of this rule using the peer groups defined in rule 5101:3-2-07.2 of the Administrative Code.

(D) Calculation of hospital-specific adjusted average cost per discharge.

Unless otherwise indicated, two types of source documents are used to obtain information needed to calculate the hospital-specific average cost per discharge defined in this rule. Those documents are the ODHS 2930 "Cost Report" and the HCFA 2552-85, as submitted to the department (ODHS or JFS as appropriate) as required in rule 5101:3-2-23 of the Administrative Code. The ODHS 2930 will be adjusted by the department in accordance with rules 5101:3-2-22, 5101:3-2-23, and 5101:3-2-24 of the Administrative Code using data made available to the department as of June 15, 1987. The documents used are those reflecting costs associated with the hospital's 1985 or 1986 fiscal year reporting period. For purposes of this rule, the 1985 cost report will be used for those hospitals with fiscal periods ending September thirtieth, October thirty-first, or December thirty-first; the 1986 cost report will be used for those hospitals with fiscal periods ending March thirty-first, May thirty-first, June thirtieth, or August thirty-first. The hospital-specific average cost per discharge component is calculated in accordance with the provisions set forth in paragraphs (D)(1) to (D)(13) of this rule.

(1) For those hospitals that have merged since the end of the fiscal year period specified in paragraph (D) of this rule and had the same fiscal reporting period, the cost reports for the hospitals will be combined. The department will combine the total cost, total charges, total days, medicaid charges, and medicaid discharges for the hospitals. A new report will be prepared by the department for the merged hospital.

(2) For those hospitals that have merged since the end of the fiscal year period specified in paragraph (D) of this rule and had different fiscal reporting periods, the procedures described in paragraphs (D)(3) to (D)(13)(d) of this rule will be followed. At that point, the average cost per discharge for the hospitals will be combined by:

(a) Multiplying the average cost per discharge for each hospital derived from paragraph (D)(12)(g) of this rule, as applicable, by the number of discharges for each hospital derived from paragraph (D)(11)(a) of this rule. Round the result to the nearest whole dollar.

(b) Sum the products.

(c) Divide the resulting sum by the sum of the hospital's discharges. Round the result to the nearest whole penny.

(3) The case-mix computation for merged providers will be performed by combining the hospital's claim records as described in paragraphs (D)(13) to (D)(13)(d) of this rule.

(4) Determination of medicaid inpatient cost adjusted to remove the cost of blood replaced by patient donors.

(a) Identify medicaid inpatient service cost on ODHS 2930, schedule H, section I, line 1, column 12.

(b) Identify cost of blood replaced by donor for medicaid inpatients on ODHS 2930, schedule H, section I, line 2, column 12.

(c) Subtract the amount identified in paragraph (D)(4)(b) of this rule from the amount identified in paragraph (D)(4)(a) of this rule.

(5) Determination of medicaid inpatient cost adjusted to include PSRO/UR cost separately identified.

(a) Identify PSRO/UR cost on ODHS 2930, schedule H, section I, line 3, column 12.

(b) Add the amount derived from paragraph (D)(5)(a) of this rule to the amount described in paragraph (D)(4)(c) of this rule.

(6) Determination of medicaid inpatient cost adjusted to include the cost of malpractice insurance.

(a) Identify the hospital's malpractice insurance premium cost on HCFA 2552-85, worksheet D-8, part II, line 11, for the hospital's fiscal reporting period ending in 1986.

(b) Compute the hospital's per cent of medicaid inpatient charges to total charges.

(i) Identify medicaid inpatient charges on ODHS 2930, schedule H, section I, line 11, column 12.

(ii) Identify total charges for all patients on ODHS 2930, schedule A, line 101B, column 1.

(iii) Divide the amount identified in paragraph (D)(6)(b)(i) of this rule by the amount identified in paragraph (D)(6)(b)(ii) of this rule. Round the result to six decimal places.

(c) For those hospitals whose fiscal year ends on or prior to December 31, 1985, divide the amount identified in paragraph (D)(6)(a) of this rule by the appropriate deflation factor described in paragraph (G)(1) of this rule. Round to the nearest whole dollar.

(d) Multiply the amount identified in paragraph (D)(6)(a) or (D)(6)(c) of this rule, as applicable, by the percentage derived from paragraph (D)(6)(b)(iii) of this rule. Round the result to the nearest dollar.

(e) Add the amount computed in paragraph (D)(6)(d) of this rule to the amount derived in paragraph (D)(5)(b) of this rule.

(7) Determination of medicaid inpatient cost adjusted to remove the direct cost of medical education.

(a) Identify the hospital direct medical education on the HCFA 2552-85, worksheet B, part I, line 95, columns 20, 21, 22, 23, and 24.

(b) Multiply the sum of the amounts in paragraph (D)(7)(a) of this rule by the percentage derived from paragraph (D)(6)(b)(iii) of this rule. Round the result to the nearest dollar.

(c) Subtract the amount computed in paragraph (D)(7)(b) of this rule from the amount computed in paragraph (D)(6)(e) of this rule.

(8) Determination of medicaid inpatient cost adjusted to remove capital-related cost.

(a) Identify the hospital capital-related cost on the HCFA 2552-85, worksheet B, part II, line 95, column 25.

(b) Multiply the amount in paragraph (D)(8)(a) of this rule by the percentage derived from paragraph (D)(6)(b)(iii) of this rule. Round the result to the nearest dollar.

(c) Subtract the amount derived from paragraph (D)(8)(b) of this rule from the amount derived from paragraph (D)(7)(c) of this rule.

(9) Determination of medicaid inpatient cost adjusted to remove the indirect cost of medical education.

(a) Identify the hospital's indirect medical education percentage described in rule 5101:3-2-07.7 of the Administrative Code. Add 1.00.

(b) Divide the amount derived from paragraph (D)(8)(c) of this rule by the factor derived in paragraph (D)(9)(a) of this rule. Round the result to the nearest dollar.

(10) Determination of medicaid inpatient cost adjusted to remove the effects of wage differences for hospitals in the teaching hospital peer group defined in rule 5101:3-2-07.2 of the Administrative Code.

(a) The labor portion of hospital cost is .7439.

(b) Multiply the amount derived from paragraph (D)(9)(b) of this rule by the labor portion of hospital cost identified in paragraph (D)(10)(a) of this rule. Round the result to the nearest whole dollar.

(c) Subtract the amount derived from paragraph (D)(10)(b) of this rule from the amount derived in paragraph (D)(9)(b) of this rule.

(d) Divide the labor portion of medicaid inpatient cost derived from paragraph (D)(10)(b) of this rule by the wage index for urban areas as published in Federal Register, Volume 51, Number 170, Wednesday, September 3, 1986, as applicable for the geographic area in which the teaching hospital is located. Round the result to the nearest whole dollar.

(e) Add the amount derived from paragraph (D)(10)(c) of this rule to the amount derived from paragraph (D)(10)(d) of this rule.

(11) Determination of medicaid inpatient hospital-specific average cost per discharge.

(a) Identify total medicaid discharges on adjusted ODHS 2930, schedule D, section II, line 6.

(b) Divide the adjusted medicaid inpatient cost derived from paragraph (D)(10)(e) or (D)(9)(b) of this rule, as applicable, by the discharges identified in paragraph (D)(11)(a) of this rule. Round the result to the nearest whole penny.

(c) For hospitals exceeding the limits described in section (III)(A) or (III)(B) of appendix A of this rule, the average cost per discharge is reduced by multiplying the amount derived from paragraph (D)(11)(b) of this rule is multiplied by .97.

(12) Determination of medicaid average cost per discharge adjusted to account for varying fiscal year ends.

(a) Compute a daily inflation factor by dividing the inflation factor for 1986 or 1987, as applicable, described in paragraph (G)(1) of this rule, by three hundred sixty-five. Round the result to six decimal places.

(b) With the exception of those hospitals whose fiscal years end on August thirty-first, compute the number of days between the hospital's fiscal year end and June 30, 1986.

(c) With the exception of those hospitals whose fiscal years end on August thirty-first, multiply the applicable daily inflation factor from paragraph (D)(12)(a) of this rule by the days computed in paragraph (D)(12)(b) of this rule. Round the result to six decimal places, then add 1.0 to yield an inflation adjustment factor.

(d) With the exception of those hospitals whose fiscal years end on August thirty-first, multiply the medicaid average cost per discharge derived from paragraph (D)(11)(b) or (D)(11)(c) of this rule by the inflation factor derived from paragraph (D)(12)(c) of this rule, as applicable. Round the result to the nearest whole penny.

(e) For those hospitals whose fiscal year ends on August thirty-first, determine the number of days from June 30, 1986 to the hospitals' fiscal year-end.

(f) For those hospitals whose fiscal year ends on August thirty-first, multiply the applicable daily inflation factor derived from paragraph (D)(12)(a) of this rule by the days derived from paragraph (D)(12)(e) of this rule. Round the result to six decimal places, then add 1.0 to yield an inflation adjustment factor.

(g) For those hospitals whose fiscal year ends on August thirty-first, divide the hospital-specific average cost per discharge derived from paragraph (D)(11)(b) or (D)(11)(c) of this rule, as applicable, by the inflation adjustment factor derived from paragraph (D)(12)(f) of this rule, as applicable. Round the result to the nearest whole penny.

(13) Determination of medicaid average cost per discharge adjusted for case mix.

For each hospital the average cost per discharge, adjusted as described in paragraphs (D)(12)(a) to (D)(12)(g) of this rule, is adjusted to remove the effects of the hospital's case mix. The data used to compute the hospital's case mix index are the hospital's claim records for discharges occurring during the hospital's fiscal period as described in paragraph (D) of this rule and paid as of May 1, 1987. For purposes of this paragraph, case mix is determined using the DRG categories and relative weights described in rule 5101:3-2-07.3 of the Administrative Code and includes outlier cases described in rule 5101:3-2-07.9 of the Administrative Code.

(a) For each hospital the number of cases in each DRG is multiplied by the relative weight for each DRG. Round the result to five decimal places. The relative weights are those described in rule 5101:3-2-07.3 of the Administrative Code.

(b) Sum the result of each computation in paragraph (D)(13)(a) of this rule.

(c) Divide the product from paragraph (D)(13)(b) of this rule by the number of cases in the hospital's sample as described in paragraph (D)(13) of this rule. Round the result to five decimal places. This produces a hospital-specific case mix index.

(d) Divide the medicaid inpatient hospital-specific average cost per discharge derived from paragraphs (D)(12)(a) to (D)(12)(g) of this rule by the hospital-specific case mix index computed in paragraph (D)(13)(c) of this rule. Round the result to the nearest whole penny.

(E) Computation of peer group average cost per discharge.

(1) Within each peer group (except for the children's hospital peer group as defined in rule 5101:3-2-07.2 of the Administrative Code), multiply each hospital's average cost per discharge from paragraph (D)(13)(d) of this rule by each hospital's number of medicaid discharges from paragraph (D)(11)(a) of this rule.

(2) Sum the results of each computation in paragraph (E)(1) of this rule.

(3) Sum the number of medicaid discharges described in paragraph (E)(1) of this rule.

(4) Divide the result derived from paragraph (E)(2) of this rule by the result derived from paragraph (E)(3) of this rule. Round the result to the nearest whole penny.

(F) Adjustments to the peer group average cost per discharge component described in paragraphs (E)(1) to (E)(4) of this rule and each children's hospital average cost per discharge component described in paragraph (D)(13)(d) of this rule are those described in paragraphs (F)(1) to (F)(3) of this rule.

(1) Disproportionate share payments will be made in accordance with rules 5101:3-2-09 and 5101:3-2-10 of the Administrative Code.

(2) An outlier set-aside is determined for each peer group except the teaching hospital and children's hospitals peer groups as described in rule 5101:3-2-07.2 of the Administrative Code. For teaching hospitals and children's hospitals identified in rule 5101:3-2-07.2 of the Administrative Code, an amount is calculated using each hospital's information to determine a hospital-specific group set-aside amount. This set-aside amount is calculated using the methodology described in paragraphs (F)(2)(a) to (F)(2)(f) of this rule.

(a) The additional payments that would be paid for outlier cases for discharges on and after July 1, 1985 to June 30, 1986 is determined using payment rates developed in accordance with this rule except that payment rates do not reflect the adjustment described in paragraph (F)(2)(f) of this rule. Relative weights as described in rule 5101:3-2-07.3 of the Administrative Code, and the day thresholds, cost thresholds, and geometric mean length of stay, excluding outliers, for each DRG as described in rule 5101:3-2-07.9 of the Administrative Code are used.

(b) For each hospital, the total additional payments made for outlier cases is divided by the sum of the total payment amount for all cases in that hospital, less payment amounts for teaching and capital allowances as described in paragraphs (H)(1) and (H)(2) of this rule and payments made for day outliers as described in paragraph (F)(2)(a) of this rule. The resulting per cent is rounded to four decimal places and represents the hospital-specific outlier per cent.

(c) For all hospitals, the total additional payment for outlier cases is calculated by summing each hospital's additional payments described in paragraph (F)(2)(a) of this rule and is divided by the summed total payment amounts for all cases in all hospitals, less payment amounts for teaching and capital allowances as described in paragraphs (H)(1) and (H)(2) of this rule, plus total payments in all hospitals for day outliers. The resulting per cent is rounded to four decimal places and represents the statewide average outlier per cent.

(d) For hospitals that have a hospital-specific outlier per cent (as described in paragraph (F)(2)(b) of this rule) over the statewide average outlier per cent as described in paragraph (F)(2)(c) of this rule, the outlier payments that are used in the peer group calculation described in paragraph (F)(2)(e) of this rule are capped by multiplying the hospital-specific additional payment amount described in paragraph (F)(2)(a) of this rule by seventy-five per cent.

(e) The outlier set-aside amount is calculated on a peer group basis using the following methodology:

(i) For each peer group except the teaching hospital and children's hospital peer groups as described in rule 5101:3-2-07.2 of the Administrative Code and for each teaching hospital and children's hospital (identified in rule 5101:3-2-07.2 of the Administrative Code), sum the total additional payments for outliers as described in paragraph (F)(2)(a) or (F)(2)(d) of this rule, as applicable.

(ii) For each peer group except the teaching hospital and children's hospital peer groups and for each teaching and children's hospital, divide the sum from paragraph (F)(2)(e)(i) of this rule by the sum of the total payment amount, less payment amounts for teaching and capital allowances as described in paragraphs (H)(1) and (H)(2) of this rule, plus total day outlier payments.

(f) The outlier adjustment amount is calculated by multiplying the percentage described in paragraph (F)(2)(e)(ii) of this rule by the applicable average cost per discharge component for each peer group as described in paragraphs (E) to (E)(4) of this rule and for each children's hospital as described in paragraph (D)(13)(d) of this rule. Round the result to the nearest whole penny to determine the outlier adjustment amount. Subtract the outlier adjustment amount from the applicable average cost per discharge component described in paragraph (F)(1)(a) of this rule for discharges occurring on and after July 1, 1988 and prior to February 1, 1989. For discharges occurring on and after February 1, 1989, subtract the outlier adjustment amount from the average cost per discharge component for each peer group as described in paragraph (E)(4) of this rule and for each children's hospital as described in paragraph (D)(13)(d) of this rule. Round the result to the nearest whole penny.

(3) For purposes of coding adjustment, the applicable average cost per discharge component described in paragraph (F) of this rule is divided by 1.005. Round the result to the nearest whole penny.

(4) For Ohio hospitals meeting the teaching hospital peer group criteria defined in rule 5101:3-2-07.2 of the Administrative Code, the peer group average cost per discharge described in paragraph (F)(3) of this rule is multiplied by a wage factor and rounded to the nearest whole penny. The wage factor is determined by dividing the amount derived from paragraph (D)(9)(b) of this rule by the amount derived from paragraph (D)(10)(e) of this rule, rounded to six decimal places.

(G) Adjustments for inflation.

In calculating the prospective payment rate, it is necessary to adjust costs to reflect inflation at various points in the calculation.

(1) In order to assure hospitals an annual allowance for inflation except as provided in paragraph (G)(2) of this rule, an inflation factor is developed. The Ohio specific "inflation factor" is a weighted average of twenty-three price and wage indexes, either regional or national. The weights are those published weights shown in this paragraph. Price growth increase values for these weighted items are determined by "Global Insight" for the department. Annual inflation factors are derived from summing the result of the following calculation for each item and adding one to produce a factor:

"Factor X Weight X Projected Price Increase"

The categories and indexes are those identified in paragraphs (G)(1)(a) to (G)(1)(t) of this rule. When more than one period is being inflated, annual factors are multiplied by one another to produce a composite factor.

(a) Wages: average hourly earnings (AHE), general medical and surgical hospitals, midwest region. The weight is .4339.

(b) Benefits: supplements to wages and salaries per employee, east north central (ENC). The weight is .0949.

(c) Professional fees, nonmedical: "Employment Cost Index" (ECI) wages and salaries, midwest region. The weight is .0213.

(d) Malpractice insurance: Health care financing administration, professional liability insurance premium index. The weight is .0119.

(e) Utilities: producer price index (PPI) - electricity, commercial sector, ENC (the weight is .0093); price of natural gas for the commercial sector, ENC (the weight is .0037); "Consumer Price Index - All Urban" CPIU -water and sewerage maintenance, U.S. (the weight is .0025). The combined weight is .0155.

(f) Prescription pharmaceuticals: PPI - pharmaceutical preparations, prescription (chemicals), U.S. The weight is .0416.

(g) Food: direct purchase, PPI - processed foods and feeds, U.S. (the weight is .0231); contract purchase, CPIU, food at home, ENC (the weight is .0107).

(h) Chemicals: PPI - industrial chemicals, U.S. The weight is .0367.

(i) Medical instruments: PPI - surgical and medical instruments and apparatus, U.S. The weight is .0308.

(j) Photographic supplies: PPI - photographic supplies, U.S. the weight is .0039.

(k) Rubber and plastics: PPI - rubber and plastics products, U.S. The weight is .0475.

(l) Paper products: PPI - paper and paperboard, U.S. The weight is .0208.

(m) Apparel: PPI - textile products and apparel, U.S. The weight is .0087.

(n) Machinery and equipment: PPI - machinery and equipment, U.S. The weight is .0021.

(o) Miscellaneous products: PPI - finished goods, U.S. The weight is .0224.

(p) Postage: CPIU - postage, U.S. The weight is .0027.

(q) Telephone services: CPIU - telephone services, U.S. The weight is .0058.

(r) All other, labor intensive: ECI - compensation business services, U.S. The weight is .0728.

(s) All other, non-labor intensive: CPIU - all items, ENC. The weight is .0080.

(t) Miscellaneous: CPIU - medical care, ENC. The weight is .0849.

(2) Application of estimated inflation factors.

The inflation values applied at the beginning of each rate year to produce a new composite inflation factor shall be based on the estimate of price indicators outlined in paragraphs (G) and (G)(1) of this rule that have been supplied to the department by three months prior to the beginning of a new rate year, except for rate years beginning on or after January 1, 2009 and ending on or before December 31, 2013 the composite inflation factor will be adjusted to 0.00 per cent. Not withstanding the 0.00 per cent composite inflation factor updates in this paragraph, for discharges occurring during the period beginning October 1, 2009 and ending June 30, 2013 a five per cent increase shall be applied to the rates in effect on September 30, 2009. The inflation factors shall be uniformly applied to the average cost per discharge component and shall remain fixed for that rate period.

(3) Calculation of inflated peer group adjusted average cost per discharge, including each children's hospital adjusted average cost per discharge.

(a) For each hospital/peer group, the peer group adjusted average cost per discharge derived from paragraph (F)(3) or (F)(4) of this rule, as applicable, is multiplied by an inflation factor derived from paragraph (G)(2) of this rule. Round the result to the nearest whole penny.

(b) For each children's hospital as defined in rule 5101:3-2-07.2 of the Administrative Code, the hospital-specific adjusted average cost per discharge derived from paragraph (F)(4) of this rule is multiplied by an inflation factor derived from paragraph (G)(2) of this rule. Round the result to the nearest whole penny.

(H) Addition of hospital-specific allowances.

Hospital-specific allowances include those described in paragraphs (H)(1) to (H)(3) of this rule.

(1) For Ohio hospitals having approved teaching programs as defined in 42 C.F.R. 405.421 as effective on October 1, 1985, an education allowance amount is added. The medical education allowance amount is described in rule 5101:3-2-07.7 of the Administrative Code.

(2) For Ohio hospitals, a hospital-specific capital allowance amount is added. The capital allowance amount is described in rule 5101:3-2-07.6 of the Administrative Code.

(3) For non-Ohio hospitals, a single capital allowance amount is added. The capital allowance amount is described in rule 5101:3-2-07.6 of the Administrative Code.

(I) The final prospective payment rate is calculated by multiplying the adjusted inflated average cost per discharge, derived from paragraphs (G)(3)(a) and (G)(3)(b) of this rule, by the relative weight appropriate to the DRG (see rule 5101:3-2-07.3 of the Administrative Code), rounding the result to the nearest whole penny, then adding all applicable hospital-specific allowance amounts described in paragraphs (H)(1) to (H)(3) of this rule, i.e.:


              image: oh/admin/2014/5101$3-2-07$4_ph_ff_a_ru_20110919_0843-1.png

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Effective: 09/29/2011
R.C. 119.032 review dates: 10/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02 , section 309.30.35 of Am. Sub. H.B. 153, 129th G.A.
Rule Amplifies: 5111.01 , 5111.02 , section 309.30.35 of Am. Sub. H.B. 153, 129th G.A.
Prior Effective Dates: 10/4/84, 7/1/85, 7/5/86, 10/19/87, 7/1/88 (Emer), 9/29/88, 7/1/89, 6/29/90 (Emer), 9/23/90, 9/3/91 (Emer), 11/10/91, 7/1/92, 7/1/93, 12/29/95 (Emer), 3/16/96, 7/1/96, 7/2/98, 1/1/00, 1/1/02, 12/31/02 (Emer), 2/6/03, 8/21/03, 12/8/05, 12/31/07 (Emer), 3/30/08, 10/1/09 (Emer), 10/15/09, 7/1/11 (Emer)

5160-2-07.5 Disproportionate share adjustment.

This rule describes the disproportionate share definition and limitations on payment methods described in rule 5101:3-2-09 of the Administrative Code for the program year specified in paragraph (A)(9) of rule 5101:3-2-08 of the Administrative Code.

(A) For the program year specified in paragraph (A)(9) of rule 5101:3-2-08 of the Administrative Code, paragraphs (B) to (D) of this rule set forth the definition of disproportionate share as well as other procedures and data used for the disproportionate share calculations as described in rule 5101:3-2-09 of the Administrative Code.

(B) Source data for calculations.

The source data used for the calculations made in paragraphs (C) and (D) of this rule will be the hospital's cost-reporting period ending in the state fiscal year as specified in paragraph (B) of rule 5101:3-2-08 of the Administrative Code.

(C) Determination of disproportionate share qualification.

(1) For each hospital calculate the medicaid utilization rate by dividing the sum of total medicaid days and managed care plan (MCP) days as defined in paragraph (A) of rule 5101:3-2-09 of the Administrative Code by total facility days as defined in paragraph (A) of rule 5101:3-2-09 of the Administrative Code.

(2) Each hospital with a medicaid utilization rate greater than or equal to one per cent qualifies as a disproportionate share hospital for the purposes of rule 5101:3-2-09 of the Administrative Code.

(3) Each hospital with a medicaid utilization rate less than one per cent qualifies as a nondisproportionate share hospital for the purposes of rule 5101:3-2-09 of the Administrative Code.

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

(1) For purposes of this rule, for each hospital, calculate medicaid fee for service (FFS) shortfall by subtracting from total medicaid costs, as defined in paragraph (A) of rule 5101:3-2-09 of the Administrative Code, total medicaid payments, as described in paragraph (A) of rule 5101:3-2-09 of the Administrative Code. For those hospitals exempt from the prospective payment system as described in rule 5101:3-2-07.1 of the Administrative Code, the medicaid shortfall equals zero.

(2) For each hospital, calculate the total medicaid shortfall by adding the medicaid FFS shortfall as defined in paragraph (D)(1) of this rule to the medicaid MCP shortfall as defined in paragraph (E)(2)(d) of rule 5101:3-2-09 of the Administrative Code.

(3) For each hospital, determine the total cost of uncompensated care for people without insurance as described in paragraphs (D)(3)(a) to (D)(3)(c) of this rule.

(a) For each hospital, "total inpatient uncompensated care costs for people without insurance" means the sum of the inpatient disability assistance medical costs, uncompensated care costs below the poverty level, and uncompensated care costs above the poverty level amounts from the JFS 02930, schedule F, column 5, line 11.

(b) For each hospital, "total outpatient uncompensated care costs for people without insurance" means the sum of the outpatient disability assistance medical costs, uncompensated care costs below the poverty level, and uncompensated care costs above the poverty level amounts from the JFS 02930, schedule F, column 5, line 15.

(c) For each hospital, total uncompensated care costs for patients without insurance is equal to the sum of paragraphs (D)(3)(a) and (D)(3)(b) of this rule.

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

(5) For each hospital, calculate the hospital disproportionate share limit by adding the total medicaid shortfall as described in paragraph (D)(2) of this rule and total uncompensated care costs for people without insurance as described in paragraph (D)(3)(c) of this rule and subtracting section 1011 payments as described in paragraph (D)(4) of this rule.

(6) The hospital will receive the lesser of the disproportionate share limit as described in paragraph (D)(5) of this rule or the disproportionate share and indigent care payment as calculated in rule 5101:3-2-09 of the Administrative Code.

Effective: 12/25/2010
R.C. 119.032 review dates: 09/23/2010 and 12/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5112.03
Rule Amplifies: 5111.02 , 5111.021 , 5112.01 , 5112.03
Prior Effective Dates: 10/19/87, 7/1/88 (Emer), 9/29/88, 7/2/92 (Emer), 9/20/92, 7/16/93 (Emer), 9/30/93, 7/24/94, 3/10/95 (Emer), 5/18/95, 3/16/96, 8/7/96 (Emer), 10/21/96, 8/25/97 (Emer), 11/1/97, 8/6/98 (Emer), 9/18/98, 9/15/99, 8/2/01, 9/15/06

5160-2-07.6 Capital costs.

(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) 2552-96 revised April 1, 2005 or CMS 2552-10 revised October 2012 and filed in accordance with CMS instructions, available at

http://www.cms.hhs.gov/manuals/pub152/PUB_15_2.asp [File Link Not Available]

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals.html [File Link Not Available] (revised September 2013).

(B) Capital-related costs for services provided on or before December 31, 2013 by Ohio hospitals paid under prospective payment will be subject to reasonable cost reimbursement. The program reimbursable amount will be reconciled during settlement to the total amount of interim capital payments associated with discharges occurring during the cost-reporting period.

Capital-related costs for services provided on or after January 1, 2014 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 paragraph (I) of rule 5160-2-07.4 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 the capital-related costs reported on CMS 2552-96; multiplying that cost by the per cent of medicaid inpatient charges to total charges; and dividing the result by 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 shall apply.

(2) For services provided on or after January 1, 2014, 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 CMS 2552-96 or CMS 2552-10; multiplying that cost by the per cent of medicaid inpatient charges to total charges; and dividing the result by 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 shall 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 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) For services provided on or before December 31, 2013, the capital allowance for non-Ohio hospitals shall be one hundred per cent of the amount calculated in paragraph (D)(1) of this rule.

(3) For services provided on or after January 1, 2014, the capital allowance for non-Ohio hospitals shall be eighty-five per cent of the amount calculated in paragraph (D)(1) of this rule.

(4) The average statewide capital cost is updated annually using capital costs from cost reports as described in paragraph (C) of this rule.

(5) 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.

Effective: 03/27/2014
R.C. 119.032 review dates: 01/10/2014 and 03/27/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02 , 5164.70
Prior Effective Dates: 10/1/84, 7/4/85, 7/3/86, 10/19/87, 6/19/00, 1/27/06, 1/1/14 (Emer.)

5160-2-07.7 Medical education.

Ohio hospitals that have an approved medical education program as defined in 42 C.F.R. 405.421 effective September 1, 1983 qualify for an allowance for medical education. This rule describes the method used to determine the medical education allowance that will be added to the diagnostic related group (DRG) base price for teaching hospitals. Source documents used are those described in paragraph (D) of rule 5101:3-2-07.4 of the Administrative Code.

(A) Direct medical education allowance.

(1) Identify the hospital's intern and resident cost as reported on the health care finance administration H.C.F.A. 2552-85 effective July 1, 1985 and available at http://www.cms.hhs.gov/manuals/pub152/PUB_15_2.asp, worksheet B, part I, line 95, column 21 and divide that cost by the number of full-time equivalent (FTE) residents and interns reported by the hospital on H.C.F.A. 2552-85, worksheet S-3, column 9, lines 8, 9, and 10.

(2) Determine the value of one standard deviation above the statewide mean cost per intern/resident. The statewide mean cost per intern/resident is determined by dividing the statewide total cost for interns and residents by the total number of FTE interns and residents in the state. The numbers used in this computation are identified in paragraph (A)(1) of this rule.

(3) Compare the hospital-specific average cost per intern/resident as described in paragraph (A)(1) of this rule with the amount derived from paragraph (A)(2) of this rule. The allowable cost per intern/resident for hospitals which that have a hospital-specific average cost per intern/resident below the amount derived from paragraph (A)(2) of this rule is the amount derived as described in paragraph (A)(1) of this rule. The allowable cost per intern/resident for hospitals that have a hospital-specific average cost per intern/resident above the amount derived from paragraph (A)(2) of this rule is the amount as described in paragraph (A)(2) of this rule.

(4) Multiply the hospital's allowable cost per intern/resident, as described in paragraph (A)(3) of this rule, by the hospital's number of FTE interns and residents.

(5) Add to the total allowed cost for interns and residents computed in paragraph (A)(4) of this rule, the hospital's costs for nursing and paramedical education from H.C.F.A.2552-85, worksheet B, line 95, columns 20, 22, 23, and 24.

(6) Multiply the total allowed direct medical education cost derived in paragraph (A)(5) of this rule by the per cent derived in paragraph (D)(6)(b)(iii) of rule 5101:3-2-07.4 of the Administrative Code. Divide this product by the number of discharges used to calculate the average cost per discharge as described in rule 5101:3-2-07.4 of the Administrative Code.

(B) Indirect medical education allowance.

(1) The hospital's indirect medical education percentage will be determined by applying the following logarithmic formula:

The number of interns and residents will be the number described in paragraph (A)(1) of this rule. The number of beds will be the number reported on H.C.F.A. 2552-85, worksheet S-3, lines 8, 9, and 10, column 1.

(2) Determine the total indirect medical education cost for a hospital by subtracting the amount derived in paragraph (D)(9)(b) of rule 5101:3-2-07.4 of the Administrative Code from the amount derived in paragraph (D)(8)(c) of rule 5101:3-2-07.4 of the Administrative Code.

(3) Determine a hospital-specific unit cost of indirect medical education by dividing the amount derived from paragraph (B)(2) of this rule by the product of one hundred times, the percentage calculated in paragraph (B)(1) of this rule. This amount is then divided by the number of discharges used to calculate the average cost per discharge as described in rule 5101:3-2-07.4 of the Administrative Code.

(4) A statewide mean unit cost for indirect medical education is determined by summing all hospitals' unit cost as described in paragraph (B)(3) of this rule, eliminating the two values that represent the highest and the lowest values, and dividing this sum by the number of values used in this calculation. The values of one standard deviation above this statewide mean cost is then determined.

(5) Compare the hospital-specific unit cost of indirect medical education as described in paragraph (B)(3) of this rule to the statewide mean unit cost plus one standard deviation as described in paragraph (B)(4) of this rule. The allowable indirect medical education unit cost for hospitals that have a hospital-specific unit cost below the statewide mean plus one standard deviation is the amount derived in paragraph (B)(3) of this rule. The allowable unit cost for hospitals with a unit cost above the statewide mean plus one standard deviation is the amount derived in paragraph (B)(4) of this rule.

(6) The allowable unit cost for indirect medical education is multiplied by one hundred, times the indirect medical education percentage described in paragraph (B)(1) of this rule to determine the indirect medical education allowance.

(C) The total medical education allowance is the sum of the indirect medical education allowance derived in paragraph (B)(6) of this rule and the direct medical education amount derived in paragraph (A)(6) of this rule, adjusted for inflation as described in paragraphs (D)(12) and (G) of rule 5101:3-2-07.4 of the Administrative Code.

(D) The total medical education allowance as described in paragraph (C) of this rule is adjusted to remove the effects of the hospital's case mix. The data used to compute the hospital's case mix index are the hospital's claim records for discharges occurring during the hospital's fiscal period, on or after April 1, 1990 through December 31, 1991, and paid by December 31, 1992. For purposes of this paragraph, case mix is determined using the DRG categories and relative weights described in rule 5101:3-2-07.3 of the Administrative Code and includes outlier cases as described in rule 5101:3-2-07.9 of the Administrative Code.

(1) For each hospital the number of cases in each DRG is multiplied by the relative weight for each DRG. Round the result to five decimal places. The relative weights are those described in rule 5101:3-2-07.3 of the Administrative Code.

(2) Sum the result of each computation in paragraph (D)(1) of this rule.

(3) Divide the product from paragraph (D)(2) of this rule by the number of cases in the hospital's sample as described in paragraph (D) of this rule. Round the result to five decimal places. This produces a hospital-specific case mix index.

(4) Divide the total medical education allowance as described in paragraph (C) of this rule by the hospital-specific case mix index computed in paragraph (D)(3) of this rule to determine the adjusted total medical education allowance. Round the result to the nearest whole penny.

(E) The adjusted total medical education allowance as described in paragraph (D) of this rule is multiplied by the relative weight appropriate to the DRG as described in rule 5101:3-2-07.3 of the Administrative Code, rounding the result to the nearest whole penny, to determine the hospital specific medical education allowance amount for the DRG.

Effective: 01/27/2006
R.C. 119.032 review dates: 11/10/2005 and 01/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.19
Rule Amplifies: 5111.01 , 5111.02 , 5111.19
Prior Effective Dates: 10/4/84, 7/1/85, 7/3/86, 10/19/87, 1/20/95, 8/1/02, 9/12/03

5160-2-07.8 Redetermination of prospective payment rates.

(A) General description.

In future years, prospective payment rates may be determined by application of a projected inflation value as set forth in paragraph (B) of this rule leaving base-year costs and relative weights unchanged. Alternatively, through revision of relevant rules in this chapter, either or both the rebasing of base-year costs or the recalibration of relative weights for DRGs may occur and may result in a significant change in the prospective payment rate. In addition to redetermination of rates associated with the beginning of a new rate year, redetermination may occur within a rate year. At the beginning of each new rate year, a ninety-day period will be provided to both the department and the hospitals for the verification of all data used in rate calculations and the detection of errors in the calculations of rate amounts following the methodologies detailed in rules 5101:3-2-07.4, 5101:3-2-07.6, and 5101:3-2-07.7 of the Administrative Code. Rule 5101:3-2-07.12 of the Administrative Code describes the procedures by which a hospital may request reconsideration of a rate component during the first ninety days of a rate year as well as the conditions under which subsequent reconsideration may be requested. Rule 5101:3-2-24 of the Administrative Code describes the conditions under which the department may initiate rate adjustments after the initial ninety-day verification period has passed. This rule describes the applicability of and procedures for redetermination of prospective rates.

(B) Application of inflation allowance.

At the start of each succeeding state fiscal year, the department shall apply a projected inflation value as defined in rule 5101:3-2-07.4 of the Administrative Code.

(C) Redetermination of peer group average cost per discharge component of the prospective payment rate.

The peer group average cost per discharge component described in paragraphs (E)(1) to (E)(4) of rule 5101:3-2-07.4 of the Administrative Code may be redetermined in accordance with paragraphs (C)(1) to (C)(3) of this rule.

(1) When reclassification of hospitals among peer groups occurs as described in paragraph (D)(2) of rule 5101:3-2-07.2 of the Administrative Code, the peer group average cost per discharge component will be redetermined if such redetermination would result in at least a two per cent difference, negative or positive, in the peer group average cost per discharge amount.

(2) The peer group average cost per discharge component will be redetermined if the use of revised or corrected hospital-specific average cost per discharge data would result in at least a two per cent difference in the peer group average cost per discharge amount subject to the provisions of this paragraph. In order to redetermine the peer group average cost per discharge under the provisions of this paragraph and paragraph (C) of this rule, the following conditions apply:

(a) Revised or corrected hospital-specific average cost per discharge data are identified under the provisions described in paragraphs (C) to (C)(3) of this rule, rule 5101:3-2-07.12, or rule 5101:3-2-24 of the Administrative Code.

(b) Data described in paragraph (C)(2)(a) of this rule is identified within two rate periods following implementation of rebased rate components.

(3) For the purposes of paragraphs (C)(1) and (C)(2) of this rule, any redeterminations of the peer group average cost per discharge component will be made in accordance with the provisions set forth in rule 5101:3-2-07.4 of the Administrative Code. If peer group rates are subject to redetermination because they meet the provision of paragraph (C)(1) or (C)(2) of this rule, the timing of the adjustment to the rate and the mechanism for retrospectively adjusting previously paid claims depends upon the magnitude of the adjustment. If the use of revised hospital-specific data for one or more hospitals in a peer group results in a change of at least five per cent in the peer group average cost per discharge, the rate adjustment will be made prospectively for admissions on or after the thirtieth day following the final administrative decision described in rule 5101:3-2-07.12 of the Administrative Code, or following the recognition by the department that an adjustment in the peer group average cost per discharge calculation is warranted, whichever is earlier. Claims previously paid that are subject to the adjustment will be adjusted retrospectively at interim settlement or can be mass adjusted if the provider requests in writing that a mass adjustment of that provider's claims be performed. If the use of revised data for one or more hospitals in a peer group results in a change of less than five per cent in the peer group average cost per discharge, the adjustment will be made prospectively for admissions on or after the first day of the next rate year and retrospectively during interim or final settlement. The retrospective adjustment of previously paid claims will be accomplished by determining the difference between the amount paid during the period that incorrect rates were in effect and the amount that would have been paid if the correct rates had been in effect and adjusting this amount by case-mix.

(D) Redetermination of a hospital-specific rate component.

Redetermination of a hospital-specific rate component as described in rules 5101:3-2-07.6 and 5101:3-2-07.7 of the Administrative Code will not be implemented until the beginning of the next prospective rate year unless the need for the change in the rate component is detected within the first ninety days of a new rate year. Adjustments to claims paid during a period when a rate component was incorrect will be made retrospectively at interim settlement. Corrections to these rate components will be made prospectively at the beginning of the following rate year.

(E) Notification of effective rates.

Prior to the beginning of each prospective payment rate year, each Ohio hospital will be given notice regarding payment rates for the upcoming prospective payment years. The payment rate information described in this paragraph will be effective for the prospective payment year, except as otherwise provided in rules 5101:3-2-07.12 and 5101:3-2-24 of the Administrative Code and this rule. Information provided in the notice described in this paragraph shall include:

(1) Peer group average cost per discharge adjusted as described in rule 5101:3-2-07.4 of the Administrative Code;

(2) Hospital-specific allowances, as applicable, for capital and medical education as described in rules 5101:3-2-07.4, 5101:3-2-07.6, and 5101:3-2- 07.7 of the Administrative Code; and

(3) Indication of whether the hospital is recognized as operating a distinct-part psychiatric unit, and/or level I, II, or III nursery unit as each are described in rule 5101:3-2-02 of the Administrative Code. Hospitals must notify the department immediately when a change in psychiatric unit distinct part and/or nursery unit occurs. Retrospective adjustment of previously paid claims to reflect the change in status of the psychiatric unit or nursery will be processed for claims with discharges beginning on the later of the effective date of the change or the first day of the rate year in which the department was notified of the change. No adjustments to paid claims will be made for claims with discharge dates that were prior to the beginning of the rate year in which the department was notified of the change.

Effective: 12/22/2007
R.C. 119.032 review dates: 09/26/2007 and 12/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 10/1/84, 7/8/85, 7/3/86, 10/19/87, 2/1/89, 7/1/90, 9/3/91 (Emer), 11/10/91, 8/1/02

5160-2-07.9 Payment for outliers.

This rule defines cost and day outliers and exceptional outliers, and describes the reimbursement methodology that will be used to pay for all types of outliers for inpatient hospitals subject to the prospective payment system. The payment policies contained in this rule are effective for dates of discharge on or after October 1, 2011.

(A) The Ohio department of job and family services ("ODJFS") will provide for an additional payment to a hospital for covered inpatient hospital services to a medicaid recipient that exceed the thresholds as described in paragraphs (A)(1) to (A)(6) of this rule.

(1) For diagnostic related groups (DRGs) 1 to 384; 391 to 468; 471 to 503: The total allowed charges for an inpatient stay exceeds the statewide arithmetic mean charge, as described in rule 5101:3-2-07.3 of the Administrative Code, for the appropriate DRG by two standard deviations.

(2) For DRGs 385; 388 to 390; 892 to 898: The total allowed charges for the inpatient stay exceeds the statewide arithmetic mean charge, as described in rule 5101:3-2-07.3 of the Administrative Code, for the applicable DRG by one standard deviation.

(3) For DRGs 1 to 384; 391 to 468; 471 to 503: The recipient's covered length of stay exceeds the statewide geometric mean length of stay for the applicable DRG by two standard deviations.

(4) For DRGs 388 to 390 and 892 to 898: The recipient's covered length of stay exceeds the statewide geometric mean length of stay for the applicable DRG by one standard deviation.

(5) If a hospital that does not meet the criteria described in paragraphs (E)(1) and (E)(2) of this rule has a discharge that qualified for both a cost and a day outlier payment, then the hospital receives payment for the case as a cost outlier only.

(6) Effective August 1, 2002, if the cost for a case determined by multiplying the allowed charges from the claim by the hospital-specific cost-to-charge ratio, determined in accordance with the provisions of paragraph (B)(2) of rule 5101:3-2-22 of the Administrative Code, exceeds four hundred forty-three thousand, four hundred sixty-three dollars, then payment will be as described in paragraph (D) of this rule. This threshold amount will be inflated on an annual basis on January first of each year by using the inflation factor described in paragraph (G)(1) of rule 5101:3-2-07.4 of the Administrative Code, that has been supplied to the department by three months prior to the beginning of the rate year.

(B) Payment for extended length of stay (day outliers).

(1) If the hospital stay reflected by a discharge includes covered days of care beyond the threshold as described in paragraphs (A)(3) and (A)(4) of this rule, an additional payment shall be made.

(2) Any case that qualifies for a day outlier payment is subject to review as described in rule 5101:3-2-07.13 of the Administrative Code.

(3) For DRGs 1 to 384; 391 to 468; 471 to 503: Except as provided in paragraph (B)(5) of this rule, the per diem payment will be based on sixty per cent of the per diem rate, except that for hospitals meeting the criteria described in paragraphs (E)(1) and (E)(2) of this rule, per diem payment will be eighty per cent of the per diem rate. The per diem rate is calculated by dividing the hospital's final prospective rate for that DRG as described in rule 5101:3-2-07.4 of the Administrative Code, less capital and teaching allowance for the applicable DRG by the statewide geometric mean length of stay, calculated excluding outliers, for that DRG.

The total day outlier payment is then determined by multiplying the number of covered days beyond the day threshold times the per diem payment amount. The total payment is the final prospective payment rate as described in rule 5101:3-2-07.4 of the Administrative Code, plus the outlier payment. If the total payment exceeds allowable charges, reimbursement is limited to allowable charges.

(4) For DRGs 388 to 390 and 892 to 898: The per diem payment will be based on eighty per cent of the per diem rate determined by dividing the hospital's final prospective payment rate for that DRG as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code, less capital and teaching allowance for the applicable DRG by the statewide geometric mean length of stay, calculated excluding outliers, for that DRG. The total day outlier payment is then determined by multiplying the number of covered days beyond the day threshold times the per diem payment amount. The total payment is the final prospective payment rate as described inrule 5101:3-2-07.4 of the Administrative Code, plus the outlier payment. If the total payment exceeds allowable charges, reimbursement is limited to allowable charges.

(5) For DRG 488, DRG 489 and DRG 490: The per diem payment for hospitals meeting the criteria described in paragraph (G) of this rule will be based on eighty per cent of the per diem rate. The per diem rate is calculated by dividing the hospital's final prospective rate for that DRG as described in rule 5101:3-2-07.4 of the Administrative Code, less capital and teaching allowance for the applicable DRG by the statewide geometric mean length of stay, calculated excluding outliers, for that DRG. The total day outlier payment is then determined by multiplying the number of covered days beyond the day threshold times the per diem payment amount. The total payment is the final prospective payment rate as determined in rule 5101:3-2-07.4 of the Administrative Code, plus the outlier payment. If the total payment exceeds allowable charges, reimbursement is limited to allowable charges.

(C) Payment for extraordinary high-charge cases (cost outliers).

(1) If the allowable charges exceed the statewide charge threshold for the applicable DRG as described in paragraphs (A)(1) and (A)(2) of this rule, an additional payment shall be made. The threshold amount for each DRG will be inflated by using the cost outlier inflation factor described in paragraphs (C)(1)(a) and (C)(1)(b) of this rule.

(a) For discharges on or after October 1, 2011 through December 31, 2011, the threshold amount for each DRG in effect on September 30, 2011 shall be inflated by 13.6 per cent.

(b) For discharges on or after January 1, 2012 through the implementation of the new DRGs established by section 309.30.30 of Amended Substitute House Bill 153 of the 129th General Assembly, the threshold amount for each DRG in effect on December 31, 2011 shall be inflated by 9.72 per cent.

(2) Any case that qualifies for a cost outlier payment is subject to review as described in rule 5101:3-2-07.13 of the Administrative Code.

(3) For DRGs 1 to 384; 391 to 468; 471 to 503: Except as otherwise provided in paragraghs (C)(5) and (C)(6) of this rule, the difference determined by subtracting the statewide charge threshold, as described in paragraph (A)(1) of this rule from allowable charges, is multiplied by the hospital-specific cost to charge ratio to determine the additional payment to be made for the outlier portion. The total payment for cost outlier claims except those described in paragraphs (C)(5) and (C)(6) of this rule is the final prospective payment rate as described in rule 5101:3-2-07.4 of the Administrative Code, plus the outlier amount.

Total reimbursement is limited to the lower of allowable claim charges or claim cost. Claim cost is calculated by multiplying allowable claim charges by the hospital specific, medicaid inpatient cost-to-charge ratio, as described in rule 5101:3-2-22 of the Administrative Code.

(4) For DRGs 385; 388 to 390; and 892 to 898: Except as otherwise provided in paragraph (C)(5) of this rule, the difference determined by subtracting the statewide charge threshold, as described in paragraph (A)(2) of this rule from the allowable charges, is multiplied by the hospital-specific cost to charge ratio to determine the additional payment to be made for the outlier portion . The total payment for cost outlier claims except those described in paragraph (C)(5) of this rule is the final prospective payment rate as described in rule 5101:3-2-07.4 of the Administrative Code, plus the outlier amount. Total reimbursement is limited to the lower of allowable claim charges or claim cost. Claim cost is calculated by multiplying allowable claim charges by the hospital specific, medicaid inpatient cost-to-charge ratio, as described in rule 5101:3-2-22 of the Administrative Code.

(5) For hospitals meeting the criteria described in paragraphs (E)(1) and (E)(2) of this rule, payment for cost outlier claims will be eighty-five per cent of the product of allowed claim charges times the hospital-specific, medicaid inpatient cost-to-charge ratio as described in rule 5101:3-2-22 of the Administrative Code.

(6) For DRG 488, DRG 489 and DRG 490: The payment for cost outlier claims for hospitals meeting the criteria described in paragraph (G) of this rule, will be eighty-five per cent of the product of allowed claim charges times the hospital-specific, medicaid inpatient cost-to-charge ratio as described in rule 5101:3-2-22 of the Administrative Code.

(D) Cases that meet the criteria described in paragraph (A)(6) of this rule will be paid the product of the hospital's allowable charges times the hospital-specific cost-to-charge ratio, as described in rule 5101:3-2-22 of the Administrative Code.

(E) Hospitals that meet the criteria described in paragraphs (E)(1) and (E)(2) of this rule are subject to the special outlier payment policies described in paragraphs (A)(6), and (C)(5) of this rule.

(1) The hospital-specific outlier per cent as described in paragraph (F)(2)(b) of rule 5101:3-2-07.4 of the Administrative Code is greater than one standard deviation over the statewide mean outlier per cent as described in paragraph (F)(2)(c) of rule 5101:3-2-07.4 of the Administrative Code.

(2) The hospital's ratio of medicaid, general assistance, and Title V inpatient days to total inpatient days as described in paragraph (F)(1)(b) of this rule is greater than one standard deviation above the statewide mean ratio of medicaid, general assistance, and Title V inpatient days to total inpatient days as described in paragraph (F)(2)(c) of this rule.

(F) The calculations described in paragraphs (F)(1) to (F)(2)(c) of this rule were performed using ODHS 2930 cost-report data submitted by hospitals as described in rule 5101:3-2-23 of the Administrative Code. For hospitals with fiscal periods ending September thirtieth, October thirty-first, or December thirty-first, the 1985 cost-report is used. For hospitals with fiscal periods ending March thirty-first, May thirty-first, June thirtieth, or August thirty-first, the 1986 cost report is used.

(1) Determination of each hospital's ratio of medicaid, general assistance, and Title V inpatient days to total inpatient days.

(a) Sum the number of days shown on the ODHS 2930, schedule D, section 1, column 6, total, for medicaid, general assistance, and Title V schedules.

(b) Divide the sum derived from paragraph (F)(1)(a) of this rule by total inpatient days as reported on the ODHS 2930, schedule D, section 1, column 4, total. Round to six decimal places.

(2) Determination of one standard deviation above the statewide mean ratio of medicaid, general assistance, and Title V inpatient days to total inpatient days.

(a) Sum the ratios derived from paragraph (F)(1)(b) of this rule across all Ohio hospitals. Divide the resulting sum by the number of hospitals to determine the statewide mean ratio.

(b) Determine the value of one standard deviation above the statewide mean ratio. Round the ratio to six decimal places.

(c) Sum the values calculated as described in paragraphs (F)(2)(a) and (F)(2)(b) of this rule to determine the value of one standard deviation above the statewide mean ratio of medicaid, general assistance, and Title V inpatient days to total inpatient days.

(G) Hospitals whose total number of cases in the claim files used for setting relative weights in accordance with rule 5101:3-2-07.3 of the Administrative Code that group into DRG 488, DRG 489, or DRG 490 is greater than two standard deviations above the statewide mean for all cases that fall into these DRGs, as described in paragraphs (G)(1)(a) to (G)(1)(c) of this rule, are subject to the special outlier payment policies described in paragraphs (B)(5) and (C)(6) of this rule.

(1) Determination of two standard deviations above the statewide mean total cases that group into DRG 488, DRG 489, or DRG 490.

(a) Sum the number of cases that group into DRG 488, DRG 489, and DRG 490 using the claim base described in paragraphs (C) to (C)(4)(b) of rule 5101:3-2-07.3 of the Administrative Code. Divide the resulting sum by the number of hospitals that had any claim group into DRG 488, DRG 489, or DRG 490.

(b) Determine the value of two standard deviations above the statewide mean number of cases.

(c) Sum the values calculated as described in paragraphs (G)(1)(a) and (G)(1)(b) of this rule to determine the value of two standard deviations above the statewide mean total number of cases in DRG 488, DRG 489, and DRG 490.

Effective: 10/01/2011
R.C. 119.032 review dates: 07/14/2011 and 10/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02 , section 309.30.30 of Am. Sub. H.B. 153, 129th G.A.
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , section 309.30.30 of Am. Sub. H.B. 153, 129th G.A.
Prior Effective Dates: 10/1/84, 7/3/86, 10/19/87, 2/1/88 (Emer.), 4/18/88, 7/1/89, 6/29/90 (Emer.), 11/10/91, 1/20/95, 8/1/02, 10/13/05, 1/1/06, 9/15/06

5160-2-07.11 Payment methodology.

(A) Payments under the prospective payment system. For inpatient hospitals subject to prospective payment as described in rule 5101:3-2-07.1 of the Administrative Code, payments are made on the basis of a prospectively determined rate as provided in rule 5101:3-2-07.4 of the Administrative Code. Additional payments may be made for services described in accordance with paragraph (C) of rule 5101:3-2-07.1 of the Administrative Code. The amount paid represents final payment based on a submission of a discharge bill. No year-end retrospective adjustment is made for prospective payment except as provided in rules 5101:3-2-07.8 and 5101:3-2-24 of the Administrative Code. Except as provided in rules 5101:3-2-24, 5101:3-2-07.13, and 5101:3-2-42 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.

(B) Amounts of payment, including all components of the prospective payment rate, DRG categories and relative weights associated with such categories, identification of outlier cases and payment methods for outliers, transfers and readmissions, and other provisions affecting amounts of payment are based on applying the provisions of this chapter to claims associated with dates of discharge on or after the effective dates of the rules in this chapter, unless otherwise specified.

(C) Hospitals must submit a claim for payment only upon a recipient's final discharge as defined in rule 5101:3-2-02 of the Administrative Code including those discharges which meet the criteria for outlier payments defined in rule 5101:3-2-07.9 of the Administrative Code unless the claim qualifies for interim billing as described in paragraph (C)(3) of this rule. Transfers and readmissions are defined and paid in accordance with the provisions of this rule. The department shall assign a DRG by using the DRG"grouper," modified as described in this paragraph. For discharges on or after February 1, 2000, the department uses the "grouper" distributed by "Health Services, Incorporated," a software package used by medicare during federal fiscal year 1998. A listing of DRG classifications is shown in appendix A of this rule. The relative weights assigned are those described in rule 5101:3-2-07.3 of the Administrative Code. Cases which would be classified in DRG 385 or DRG 456 because of a transfer or death, but which involve a length of stay greater than fifteen days, are classified in the DRG which is otherwise appropriate if the transfer or death is not considered. For cases classified into DRG 386, two subgroups are created based upon the ICD-9-CM code. One subgroup is determined by cases which have ICD-9-CM code 765.0 listed as one of its diagnoses. The second subgroup is comprised of those cases that are grouped into DRG 386, but do not have 765.0 listed as a diagnosis. In accordance with rule 5101:3-2-07.3 of the Administrative Code, different relative weights are assigned to the second DRG 386 subgroup depending on whether one, the hospital operates a level I or level II nursery, or two, a level III nursery. For cases classified into DRG 387, two subgroups are created based upon birthweight. Infants with weights of zero to one thousand seven hundred fifty grams are grouped into one subgroup and infants with weights of one thousand seven hundred fifty-one grams and above are grouped into another subgroup. In accordance with rule 5101:3-2-07.3 of the Administrative Code, different relative weights are assigned to each DRG 387 subgroup depending on whether one, the hospital operates a level I or II nursery, or two, a level III nursery. Prior to submitting a claim to the DRG"Grouper," each claim will be submitted to the medicare clinical editor to ensure that the information on the claim is complete and consistent . Each discharge will be assigned to only one DRG regardless of the number of conditions treated or services furnished by a hospital, except as provided in paragraph (C)(1) of this rule.

(1) 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 if the services are assigned to DRGs 425 to 435. If the services provided in both the acute care section and the psychiatric unit distinct part are assigned to any combination of DRGs 425 to 435, payment will be made only for that DRG assigned as a result of the information on a claim submitted by the hospital for services provided from the date of admission to the hospital through the date of discharge or transfer from the hospital. If separate claims are submitted for any combination of DRGs 425 to 435, only the first claim processed will be paid. 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.

In accordance with rule 5101:3-2-03 of the Administrative Code, no coverage is available for days of inpatient care which occur solely for the provision of rehabilitation services related to a chemical dependency. Therefore, ICD-9-CM procedure codes which must be present for a claim to group to either DRG 436 or 437, will not be submitted to the DRG"grouper."

(2) For claims with discharge dates after September 3, 1991 which are rejected by the clinical editor as a result of an age, diagnosis code conflict, and the accuracy of the information contained on the claim is confirmed by the hospital, the prospective payment amount will be eighty-five per cent of the product of allowed claim charges times the hospital-specific, medicaid inpatient cost-to-charge ratio as described in paragraph (B)(2) of rule 5101:3-2-22 of the Administrative Code.

(3) 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 cost-to-charge ratio as described in paragraph (B)(2) of rule 5101:3-2-22 of the Administrative Code. For those hospitals which are not required to file a cost report under the provisions of rule 5101:3-2-23 of the Administrative Code, the statewide average inpatient cost-to-charge ratio as described in paragraph (B)(2) of rule 5101:3-2-22 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.

(D) Payments for transfers as defined in rule 5101:3-2-02 of the Administrative Code are subject to the provisions of paragraphs (D)(1) and (D)(2) of this rule.

(1) Payment to the transferring hospital. If a hospital paid under the prospective payment system transfers an inpatient to another hospital and that transfer is appropriate as defined in rule 5101:3-2-07.13 of the Administrative Code, then the transferring hospital is paid a per diem rate for each day of the patient's stay in that hospital, plus capital and teaching allowances, as applicable, not to exceed, for nonoutlier cases, the final prospective payment rate that would have been paid for the appropriate DRG as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code, except when that case is grouped into DRG 385 or DRG 456. Cases which are grouped into DRG 385 or DRG 456 are paid the full DRG payment in accordance with rule 5101:3-2-07.4 of the Administrative Code. Except for DRG 385 and DRG 456, when a patient is transferred, the department's payment is based on the DRG under which the patient was treated at each hospital. The per diem rate is determined by dividing the product of the hospital's adjusted inflated average cost per discharge multiplied by the DRG relative weight as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code by the statewide geometric mean length of stay calculated excluding outliers for the specific DRG as described in rule 5101:3-2-07.3 of the Administrative Code into which the case falls.

(2) Payment to the discharging hospital. A hospital which receives a transfer and subsequently discharges that individual (as defined in rule 5101:3-2-02 of the Administrative Code) is paid a per diem rate for each day of the patient's stay in that hospital, plus capital and teaching allowances, as applicable, not to exceed, for nonoutlier cases, the final prospective payment rate amount that would have been paid for the appropriate DRG as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code. When a patient is transferred, the department's payment is based on the DRG under which the patient was treated at each hospital. The per diem rate is determined by dividing the product of the hospital's adjusted inflated average cost per discharge multiplied by the DRG relative weight as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code by the geometric mean length of stay calculated excluding outliers for the specific DRG as described in rule 5101:3-2-07.3 of the Administrative Code into which the case falls.

(E) Outlier payments. In addition to the payment provisions described in this rule, any hospital that is involved in discharging or transferring a patient as defined in rule 5101:3-2-02 of the Administrative Code or that provides services to a medicaid patient who is partially eligible as described in paragraph (K) of this rule may qualify for additional payments in the form of outlier payments as described in rule 5101:3-2-07.9 of the Administrative Code.

(F) Readmissions are defined in rule 5101:3-2-02 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.

(G) Claims for payment for inpatient hospital services must be submitted on the UB-92 as provided in rule 5101:3-2-02 of the Administrative Code and include the data essential to assignment of a DRG. Claims assigned to DRGs 469, and 470 will be denied due to ungroupable coding.

(H) Claims for payment for discharges that may qualify for outlier payment may be billed only after discharge unless the claim qualifies for interim billing as described in paragraph (C)(3) of this rule. The claim will be processed for payment of the appropriate DRG prospective discharge payment rate as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code and outlier payments as described in rule 5101:3-2-07.9 of the Administrative Code.

(I) Providers must submit a new claim with a copy of the remittance statement and a completed adjustment request form as described in rule 5101:3-1-19.3 of the Administrative Code in order to adjust any claim which results in an improper assignment of a DRG or to correct any information provided.

(J) In the case of deliveries, the department requires hospitals to submit separate UB-92 invoices based respectively on the mother's individual eligibility and the child's individual eligibility.

(K) 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 plus the allowance for capital and teaching, as applicable. The per diem payment will be determined by dividing the product of the hospital's adjusted inflated average cost per discharge multiplied by the DRG relative weight for the DRG as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code by the statewide geometric mean length of stay calculated excluding outliers for that DRG as described in rule 5101:3-2-07.3 of the Administrative Code. The per diem amount will be multiplied times the number of covered days for which the patient was medicaid-eligible during the hospitalization. Payment for a nonoutlier case cannot exceed the final prospective payment rate for the DRG as described in paragraph (I) of rule 5101:3-2-07.4 of the Administrative Code.

Eff 10-1-84; 7-1-85; 7-3-86; 10-19-87; 6-30-89 (Emer.); 7-21-89; 7-1-90; 9-3-91 (Emer.); 11-10-91; 7-1-92; 1-20-95; 2-1-00; 8-1-02; 6-1-04
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01 , 5111.02
R.C. 119.032 review dates: 03/12/2004 and 06/01/2009
Appendix A Diagnosis Related Groups, Version 15.0
001,MDC 01P,craniotomy age greater than 17 except for trauma
002,MDC 01P,craniotomy for trauma age greater than 17
003,MDC 01P,craniotomy age 0-17
004,MDC 01P,spinal procedures
005,MDC 01P,extracranial vascular procedures
006,MDC 01P,carpal tunnel release
007,MDC 01P,periph & cranial nerve & other nerv syst proc W CC
008,MDC 01P,periph & cranial nerve & other nerv syst proc W/O CC
009,MDC 01M,spinal disorders & injuries
010,MDC 01M,nervous system neoplasms W CC
011,MDC 01M,nervous system neoplasms W/O CC
012,MDC 01M,degenerative nervous system disorders
013,MDC 01M,multiple sclerosis & cerebellar ataxia
014,MDC 01M,specific cerebrovascular disorders except tia
015,MDC 01M,transient ischemic attack & precerebral occlusions
016,MDC 01M,nonspecific cerebrovascular disorders W CC
017,MDC 01M,nonspecific cerebrovascular disorders W/O CC
018,MDC 01M,cranial & peripheral nerve disorders W CC
019,MDC 01M,cranial & peripheral nerve disorders W/O CC
020,MDC 01M,nervous system infection except viral meningitis
021,MDC 01M,viral meningitis
022,MDC 01M,hypertensive encephalopathy
023,MDC 01M,nontraumatic stupor & coma
024,MDC 01M,seizure & headache age> 17 W CC
025,MDC 01M,seizure & headache age> 17 W/O CC
026,MDC 01M,seizure & headache age 0-17
027,MDC 01M,traumatic stupor & coma, coma>1 HR
028,MDC 01M,traumatic stupor & coma, coma>1 HR age>17 W CC
029,MDC 01M,traumatic stupor & coma, coma>1 HR age>17 W/O CC
030,MDC 01M,traumatic stupor & coma, coma<<1 HR age 0-17
031,MDC 01M,concussion age> 17 W CC
032,MDC 01M,concussion age> 17 W/O CC
033,MDC 01M,concussion age 0-17
034,MDC 01M,other disorders of nervous system W CC
035,MDC 01M,Other disorders of nervous system W/O CC
036,MDC 02P,Retinal procedures
037,MDC 02P,Orbital procedures
038,MDC 02P,Primary IRIS procedures
039,MDC 02P,Lens procedures with or without vitrectomy
040,MDC 02P,Extraocular procedures except orbit age>17
041,MDC 02P,Extraocular procedures except orbit age 0-17
042,MDC 02P,Intraocular procedures except retina, iris & lens
043,MDC 02M,Hyphema
044,MDC 02M,Acute major eye infections
045,MDC 02M,Neurological eye disorders
046,MDC 02M,Other disorders of the eye age> 17 W CC
047,MDC 02M,Other disorders of the eye age> 17 W/O CC
048,MDC 02M,Other disorders of the eye age 0-17
049,MDC 03P,Major head & neck procedures
050,MDC 03P,Sialoadenectomy
051,MDC 03P,Salivary gland procedures except sialoadenectomy
052,MDC 03P,Cleft lip & palate repair
053,MDC 03P,Sinus & mastoid procedures age>17
054,MDC 03P,Sinus & mastoid procedures age 0-17
055,MDC 03P,Miscellaneous ear, nose, mouth & throat procedures
056,MDC 03P,Rhinoplasty
057,MDC 03P,T&A proc, Except tonsillectomy &/or adenoidectomy only, age>17
058,MDC 03P,T&A proc, Except tonsillectomy &/or adenoidectomy only, age 0-17
059,MDC 03P,Tonsillectomy &/or adenoidectomy only, age>17
060,MDC 03P,Tonsillectomy &/or adenoidectomy only, age 0-17
061,MDC 03P,Myringotomy W tube insertion age>17
062,MDC 03P,Myringotomy W tube insertion age 0-17
063,MDC 03P,Other ear, nose, mouth & throat O.R. procedures
064,MDC 03M,Ear, nose, mouth & throat malignancy
065,MDC 03M,Dysequilibrium
066,MDC 03M,Epistaxis
067,MDC 03M,Epiglottitis
068,MDC 03M,Otitis media & URI age>17 W CC
069,MDC 03M,Otitis media & URI age>17 W/O CC
070,MDC 03M,Otitis media & URI age 0-17
071,MDC 03M,Laryngotracheitis
072,MDC 03M,Nasal trauma & deformity
073,MDC 03M,Other ear, nose, mouth & throat diagnoses age>17
074,MDC 03M,Other ear, nose, mouth & throat diagnoses age 0-17
075,MDC 04P,Major chest procedures
076,MDC 04P,Other resp system O.R. procedures W CC
077,MDC 04P,Other resp system O.R. procedures W/O CC
078,MDC 04M,Pulmonary embolism
079,MDC 04M,Respiratory infections & inflammations age>17 W CC
080,MDC 04M,Respiratory infections & inflammations age>17 W/O CC
081,MDC 04M,Respiratory infections & inflammations age 0-17
082,MDC 04M,Respiratory neoplasms
083,MDC 04M,Major chest trauma W CC
084,MDC 04M,Major chest trauma W/O CC
085,MDC 04M,Pleural effusion W CC
086,MDC 04M,Pleural effusion W/O CC
087,MDC 04M,Pulmonary edema & respiratory failure
088,MDC 04M,Chronic obstructive pulmonary disease
089,MDC 04M,Simple pneumonia & pleurisy age>17 W CC
090,MDC 04M,Simple pneumonia & pleurisy age>17 W/O CC
091,MDC 04M,Simple pneumonia & pleurisy age 0-17
092,MDC 04M,Interstitial lung disease W CC
093,MDC 04M,Interstitial lung disease W/O CC
094,MDC 04M,Pneumothorax W CC
095,MDC 04M,Pneumothorax W/O CC
096,MDC 04M,Bronchitis & asthma age>17 W CC
097,MDC 04M,Bronchitis & asthma age>17 W/O CC
098,MDC 04M,Bronchitis & asthma age 0-17
099,MDC 04M,Respiratory signs & symptoms W CC
100,MDC 04M,Respiratory signs & symptoms W/O CC
101,MDC 04M,other respiratory system diagnoses W CC
102,MDC 04M,other respiratory system diagnoses W/O CC
103,MDC 05P,heart transplant
104,MDC 05P,cardiac valve procedures W cardiac cath
105,MDC 05P,cardiac valve procedures W/O cardiac cath
106,MDC 05P,coronary bypass W cardiac cath
107,MDC 05P,coronary bypass W/O cardiac cath
108,MDC 05P,other cardiothoracic procedures
110,MDC 05P,major cardiovascular procedures W CC
111,MDC 05P,major cardiovascular procedures W/O CC
112,MDC 05P,percutaneous cardiovascular procedures
113,MDC 05P,amputation for circ system disorders except upper limb & toe
114,MDC 05P,upper limb & toe amputation for circ system disorders
115,MDC 05P,prm card pacem impl W ami,hrt fail or shk,or aicd lead or gnrtr proc
116,MDC 05P,oth perm card pacemak impl or ptca W coronary artery stent implnt
117,MDC 05P,cardiac pacemaker revision except device replacement
118,MDC 05P,cardiac pacemaker device replacement
119,MDC 05P,vein ligation & stripping
120,MDC 05P,other circulatory system O.R. procedures
121,MDC 05M,circulatory disorders W ami & major comp, discharged alive
122,MDC 05M,circulatory disorders W ami W/O major comp, discharged alive
123,MDC 05M,circulatory disorders W ami, expired
124,MDC 05M,circulatory disorders except ami, W card cath & complex diag
125,MDC 05M,circulatory disorders except ami, W card cath W/O complex diag
126,MDC 05M,acute & subacute endocarditis
127,MDC 05M,heart failure & shock
128,MDC 05M,deep vein thrombophlebitis
129,MDC 05M,cardiac arrest, unexplained
130,MDC 05M,peripheral vascular disorders W CC
131,MDC 05M,peripheral vascular disorders W/O CC
132,MDC 05M,atherosclerosis W CC
133,MDC 05M,atherosclerosis W/O CC
134,MDC 05M,hypertension
135,MDC 05M,cardiac congenital & valvular disorders age>17 W CC
136,MDC 05M,cardiac congenital & valvular disorders age>17 W/O CC
137,MDC 05M,cardiac congenital & valvular disorders age 0-17
138,MDC 05M,cardiac arrhythmia & conduction disorders W CC
139,MDC 05M,cardiac arrhythmia & conduction disorders W/O CC
140,MDC 05M,angina pectoris
141,MDC 05M,syncope & collapse W CC
142,MDC 05M,syncope & collapse W/O CC
143,MDC 05M,chest pain
144,MDC 05M,other circulatory system diagnoses W CC
145,MDC 05M,other circulatory system diagnoses W/O CC
146,MDC 06P,rectal resection W CC
147,MDC 06P,rectal resection W/O CC
148,MDC 06P,major small & large bowel procedures W CC
149,MDC 06P,major small & large bowel procedures W/O CC
150,MDC 06P,peritoneal adhesiolysis W CC
151,MDC 06P,peritoneal adhesiolysis W/O CC
152,MDC 06P,minor small & large bowel procedures W CC
153,MDC 06P,minor small & large bowel procedures W/O CC
154,MDC 06P,stomach, esophageal & duodenal procedures age>17 W CC
155,MDC 06P,stomach, esophageal & duodenal procedures age>17 W/O CC
156,MDC 06P,stomach, esophageal & duodenal procedures age 0-17
157,MDC 06P,anal & stomal procedures W CC
158,MDC 06P,anal & stomal procedures W/O CC
159,MDC 06P,hernia procedures except inguinal & femoral age>17 W CC
160,MDC 06P,hernia procedures except inguinal & femoral age>17 W/O CC
161,MDC 06P,inguinal & femoral hernia procedures age>17 W CC
162,MDC 06P,inguinal & femoral hernia procedures age>17 W/O CC
163,MDC 06P,hernia procedures age 0-17
164,MDC 06P,appendectomy W complicated principal diag W CC
165,MDC 06P,appendectomy W complicated principal diag W/O CC
166,MDC 06P,appendectomy W/O complicated principal diag W CC
167,MDC 06P,appendectomy W/O complicated principal diag W/O CC
168,MDC 03P,Mouth Procedures W CC
169,MDC 03P,Mouth Procedures W/O CC
170,MDC 06P,other digestive system O.R. procedures W CC
171,MDC 06P,other digestive system O.R. procedures W/O CC
172,MDC 06M,digestive malignancy W CC
173,MDC 06M,digestive malignancy W/O CC
174,MDC 06M,G.I. Hemorrhage W CC
175,MDC 06M,G.I. Hemorrhage W/O CC
176,MDC 06M,Complicated Peptic Ulcer
177,MDC 06M,Uncomplicated Peptic Ulcer W CC
178,MDC 06M,Uncomplicated Peptic Ulcer W/O CC
179,MDC 06M,Inflammatory Bowel Disease
180,MDC 06M,G.I. Obstruction W CC
181,MDC 06M,G.I. Obstruction W/O CC
182,MDC 06M,Esophagitis, gastroent & misc digest disorders age>17 W CC
183,MDC 06M,Esophagitis, gastroent & misc digest disorders age>17 W/O CC
184,MDC 06M,Esophagitis, gastroent & misc digest disorders age 0-17
185,MDC 03M,Dental & oral dis except extractions & restorations, age>17
186,MDC 03M,Dental & oral dis except extractions & restorations, age 0-17
187,MDC 03M,Dental extractions & restorations
188,MDC 06M,Other digestive system diagnoses age>17 W CC
189,MDC 06M,Other digestive system diagnoses age>17 W/O CC
190,MDC 06M,Other digestive system diagnoses age 0-17
191,MDC 07P,Pancreas, liver & shunt procedures W CC
192,MDC 07P,Pancreas, liver & shunt procedures W/O CC
193,MDC 07P,Biliary tract proc except only cholecyst W or W/O C.D.E. W CC
194,MDC 07P,Biliary tract proc except only cholecyst W or W/O C.D.E. W/O CC
195,MDC 07P,Cholecystectomy W C.D.E. W CC
196,MDC 07P,Cholecystectomy W C.D.E. W/O CC
197,MDC 07P,Cholecystectomy except by laparoscope W/O C.D.E. W CC
198,MDC 07P,Cholecystectomy except by laparoscope W/O C.D.E. W/O CC
199,MDC 07P,Hepatobiliary diagnostic procedure for malignancy
200,MDC 07P,Hepatobiliary diagnostic procedure for non-malignancy
201,MDC 07P,Other hepatobiliary or pancreas O.R. procedures
202,MDC 07M,Cirrhosis & alcoholic hepatitis
203,MDC 07M,Malignancy of hepatobiliary system or pancreas
204,MDC 07M,Disorders of pancreas except malignancy
205,MDC 07M,Disorders of liver except malig,cirr,alc hepa W CC
206,MDC 07M,Disorders of liver except malig,cirr,alc hepa W/O CC
207,MDC 07M,Disorders of the biliary tract W CC
208,MDC 07M,Disorders of the biliary tract W/O CC
209,MDC 08P,Major joint & limb reattachment procedures of lower extremity
210,MDC 08P,Hip & femur procedures except major joint age>17 W CC
211,MDC 08P,Hip & femur procedures except major joint age>17 W/O CC
212,MDC 08P,Hip & femur procedures except major joint age 0-17
213,MDC 08P,Amputation for musculoskeletal system & conn tissue disorders
216,MDC 08P,Biopsies of musculoskeletal system & connective tissue
217,MDC 08P,Wnd debrid & skn grft except hand,for muscskelet & conn tiss dis
218,MDC 08P,Lower extrem & humer proc except hip,foot,femur age>17 W CC
219,MDC 08P,Lower extrem & humer proc except hip,foot,femur age> 17 W/O CC
220,MDC 08P,Lower extrem & humer proc except hip,foot,femur age 0-17
223,MDC 08P,Major shoulder/elbow proc, or other upper extremity proc W CC
224,MDC 08P,Shoulder,elbow or forearm proc,exc major joint proc, W/O CC
225,MDC 08P,Foot procedures
226,MDC 08P,Soft tissue procedures W CC
227,MDC 08P,Soft tissue procedures W/O CC
228,MDC 08P,Major thumb or joint proc, or oth hand or wrist proc W CC
229,MDC 08P,Hand or wrist proc, except major joint proc, W/O CC
230,MDC 08P,Local excision & removal of int fix devices of hip & femur
231,MDC 08P,Local excision & removal of int fix devices except hip & femur
232,MDC 08P,Arthroscopy
233,MDC 08P,Other musculoskelet sys & conn tiss O.R. proc W CC
234,MDC 08P,Other musculoskelet sys & conn tiss O.R. proc W/O CC
235,MDC 08M,Fractures of femur
236,MDC 08M,Fractures of hip & pelvis
237,MDC 08M,Sprains,strains, & dislocations of hip, pelvis & thigh
238,MDC 08M,Osteomyelitis
239,MDC 08M,Pathological fractures & musculoskeletal & conn tiss malignancy
240,MDC 08M,Connective tissue disorders W CC
241,MDC 08M,Connective tissue disorders W/O CC
242,MDC 08M,Septic arthritis
243,MDC 08M,Medical back problems
244,MDC 08M,Bone diseases & specific arthropathies W CC
245,MDC 08M,Bone diseases & specific arthropathies W/O CC
246,MDC 08M,Non-specific arthropathies
247,MDC 08M,Signs & symptoms of musculoskeletal system & conn tissue
248,MDC 08M,Tendonitis, myositis & bursitis
249,MDC 08M,Aftercare, musculoskeletal system & connective tissue
250,MDC 08M,FX, SPRN, STRN & DISL of forearm, hand, foot age> 17 W CC
251,MDC 08M,FX, SPRN, STRN & DISL of forearm, hand, foot age> 17 W/O CC
252,MDC 08M,FX, SPRN, STRN & DISL of forearm, hand, foot age 0-17
253,MDC 08M,FX, SPRN, STRN & DISL of uparm,lowleg ex foot age> 17 W CC
254,MDC 08M,FX, SPRN, STRN & DISL of uparm,lowleg ex foot age> 17 W/O CC
255,MDC 08M,FX, SPRN, STRN & DISL of uparm,lowleg ex foot age 0-17
256,MDC 08M,Other musculoskeletal system & connective tissue diagnoses
257,MDC 09P,Total mastectomy for malignancy W CC
258,MDC 09P,Total mastectomy for malignancy W/O CC
259,MDC 09P,Subtotal mastectomy for malignancy W CC
260,MDC 09P,Subtotal mastectomy for malignancy W/O CC
261,MDC 09P,Breast proc for non-malignancy except biopsy & local excision
262,MDC 09P,Breast biopsy & local excision for non-malignancy
263,MDC 09P,Skin graft &/or debrid for SKN ulcer or cellulitis W CC
264,MDC 09P,Skin graft &/or debrid for SKN ulcer or cellulitis W/O CC
265,MDC 09P,Skin graft &/or debrid except for skin ulcer or cellulitis W CC
266,MDC 09P,Skin graft &/or debrid except for skin ulcer or cellulitis W/O CC
267,MDC 09P,Perianal & pilonidal procedures
268,MDC 09P,Skin, subcutaneous tissue & breast plastic procedures
269,MDC 09P,Other skin, subcut tiss & breast proc W CC
270,MDC 09P,Other skin, subcut tiss & breast proc W/O CC
271,MDC 09M,Skin ulcers
272,MDC 09M,Major skin disorders W CC
273,MDC 09M,Major skin disorders W/O CC
274,MDC 09M,Malignant breast disorders W CC
275,MDC 09M,Malignant breast disorders W/O CC
276,MDC 09M,Non-maligant breast disorders
277,MDC 09M,Cellulitis age> 17 W CC
278,MDC 09M,Cellulitis age> 17 W/O CC
279,MDC 09M,Cellulitis age 0-17
280,MDC 09M,Trauma to the skin, subcut tiss & breast age> 17 W CC
281,MDC 09M,Trauma to the skin, subcut tiss & breast age> 17 W/O CC
282,MDC 09M,Trauma to the skin, subcut tiss & breast age 0-17
283,MDC 09M,Minor skin disorders W CC
284,MDC 09M,Minor skin disorders W/O CC
285,MDC 10P,Amputat of lower limb for endocrine,nutrit,& metabol disorders
286,MDC 10P,Adrenal & pituitary procedures
287,MDC 10P,Skin grafts & wound debrid for endoc, nutrit & metab disorders
288,MDC 10P,O.R. Procedures for obesity
289,MDC 10P,Parathyroid procedures
290,MDC 10P,Thyroid procedures
291,MDC 10P,Thyroglossal procedures
292,MDC 10P,Other endocrine, nutrit & metab O.R. proc W CC
293,MDC 10P,Other endocrine, nutrit & metab O.R. proc W/O CC
294,MDC 10M,Diabetes age> 35
295,MDC 10M,Diabetes age 0-35
296,MDC 10M,Nutritional & misc metabolic disorders age> 17 W CC
297,MDC 10M,Nutritional & misc metabolic disorders age> 17 W/O CC
298,MDC 10M,Nutritional & misc metabolic disorders age 0-17
299,MDC 10M,Inborn errors of metabolism
300,MDC 10M,Endocrine disorders W CC
301,MDC 10M,Endocrine disorders W/O CC
302,MDC 11P,Kidney transplant
303,MDC 11P,Kidney,ureter & major bladder procedures for neoplasm
304,MDC 11P,Kidney,ureter & major bladder proc for non-neopl W CC
305,MDC 11P,Kidney,ureter & major bladder proc for non-neopl W/O CC
306,MDC 11P,Prostatectomy W CC
307,MDC 11P,Prostatectomy W/O CC
308,MDC 11P,Minor bladder procedures W CC
309,MDC 11P,Minor bladder procedures W/O CC
310,MDC 11P,Transurethral procedures W CC
311,MDC 11P,Transurethral procedures W/O CC
312,MDC 11P,Urethral procedures,age>17 W CC
313,MDC 11P,Urethral procedures,age>17 W/O CC
314,MDC 11P,Urethral procedures,age 0-17
315,MDC 11P,Other kidney & urinary tract O.R. procedures
316,MDC 11M,Renal failure
317,MDC 11M,Admit for renal dialysis
318,MDC 11M,Kidney & urinary tract neoplasms W CC
319,MDC 11M,Kidney & urinary tract neoplasms W/O CC
320,MDC 11M,Kidney & urinary tract infections age> 17 W CC
321,MDC 11M,Kidney & urinary tract infections age> 17 W/O CC
322,MDC 11M,Kidney & urinary tract infections age 0-17
323,MDC 11M,Urinary stones W CC, &/or ESW lithotripsy
324,MDC 11M,Urinary stones W/O CC
325,MDC 11M,Kidney & urinary tract signs & symptoms age> 17 W CC
326,MDC 11M,Kidney & urinary tract signs & symptons age> 17 W/O CC
327,MDC 11M,Kidney & urinary tract signs & symptons age 0-17
328,MDC 11M,Urethral stricture age>17 W CC
329,MDC 11M,Urethral stricture age>17 W/O CC
330,MDC 11M,Urethral stricture age 0-17
331,MDC 11M,Other kidney & urinary tract diagnoses age>17 W CC
332,MDC 11M,Other kidney & urinary tract diagnoses age>17 W/O CC
333,MDC 11M,Other kidney & urinary tract diagnoses age 0-17
334,MDC 12P,Major male pelvic procedures W CC
335,MDC 12P,Major male pelvic procedures W/O CC
336,MDC 12P,Transurethral prostatectomy W CC
337,MDC 12P,Transurethral prostatectomy W/O CC
338,MDC 12P,Testes procedures, for malignancy
339,MDC 12P,Testes procedures, non-malignancy age>17
340,MDC 12P,Testes procedures, non-malignancy age 0-17
341,MDC 12P,Penis procedures
342,MDC 12P,Circumcision age>17
343,MDC 12P,Circumcision age 0-17
344,MDC 12P,Other male reproductive system O.R. procedures for malignancy
345,MDC 12P,Other male reproductive system O.R. proc except for malignancy
346,MDC 12M,Malignancy, male reproductive system, W CC
347,MDC 12M,Malignancy, male reproductive system, W/O CC
348,MDC 12M,Benign prostatic hypertrophy W CC
349,MDC 12M,Benign prostatic hypertrophy W/O CC
350,MDC 12M,Inflammation of the male reproductive system
351,MDC 12M,Sterilization, male
352,MDC 12M,Other male reproductive system diagnoses
353,MDC 13P,PEL VIC evisceration, radical hysterectomy & radical vulvectomy
354,MDC 13P,Uterine,adnexa proc for non-ovarian/adnexal malig W CC
355,MDC 13P,Uterine,adnexa proc for non-ovarian/adnexal malig W/O CC
356,MDC 13P,Female reproductive system reconstructive procedures
357,MDC 13P,Uterine & adnexa proc for ovarian or adnexal malignancy
358,MDC 13P,Uterine & adnexa proc for non-malignancy W CC
359,MDC 13P,Uterine & adnexa proc for non-malignancy W/O CC
360,MDC 13P,Vagina, cervix & vulva procedures
361,MDC 13P,Laparoscopy & incisional tubal interruption
362,MDC 13P,Endoscopic tubal interruption
363,MDC 13P,D&C, Conization & radio-implant, for malignancy
364,MDC 13P,D&C, Conization except for malignancy
365,MDC 13P,Other female reproductive system O.R. procedures
366,MDC 13M,Malignancy, female reproductive system W CC
367,MDC 13M,Malignancy, female reproductive system W/O CC
368,MDC 13M,Infections, female reproductive system
369,MDC 13M,Menstrual & other female reproductive system disorders
370,MDC 14P,Cesarean section W CC
371,MDC 14P,Cesarean section W/O CC
372,MDC 14M,Vaginal delivery W complicating diagnoses
373,MDC 14M,Vaginal delivery W/O complicating diagnoses
374,MDC 14P,Vaginal delivery W sterilization &/OR D&C
375,MDC 14P,Vaginal delivery W O.R. proc except steril &/OR D&C
376,MDC 14M,Postpartum & post abortion diagnoses W/O O.R. procedure
377,MDC 14P,Postpartum & post abortion diagnoses W O.R. procedure
378,MDC 14M,Ectopic pregnancy
379,MDC 14M,Threatened abortion
380,MDC 14M,Abortion W/O D&C
381,MDC 14P,Abortion W D&C, aspiration curettage or hysterotomy
382,MDC 14M,False labor
383,MDC 14M,Other antepartum diagnoses W medical complications
384,MDC 14M,Other antepartum diagnoses W/O medical complications
385,MDC 15M,Neonates, died or transferred to another acute care facility
386,MDC 15M,Extreme immaturity or respiratory distress syndrome, neonate
387,MDC 15M,Prematurity W major problems
388,MDC 15M,Prematurity W/O major problems
389,MDC 15M,Full term neonate W major problems
390,MDC 15M,Neonate W other significant problems
391,MDC 15M,Normal newborn
392,MDC 16P,Splenectomy age>17
393,MDC 16P,Splenectomy age 0-17
394,MDC 16P,Other O.R. procedures of the blood and blood forming organs
395,MDC 16M,Red blood cell disorders age>17
396,MDC 16M,Red blood cell disorders age 0-17
397,MDC 16M,Coagulation disorders
398,MDC 16M,Reticuloendothelial & immunity disorders W CC
399,MDC 16M,Reticuloendothelial & immunity disorders W/O CC
400,MDC 17P,Lymphoma & leukemia W major O.R. procedure
401,MDC 17P,Lymphoma & non-acute leukemia W other O.R. proc W CC
402,MDC 17P,Lymphoma & non-acute leukemia W other O.R. proc W/O CC
403,MDC 17M,Lymphoma & non-acute leukemia W CC
404,MDC 17M,Lymphoma & non-acute leukemia W/O CC
405,MDC 17M,Acute leukemia W/O major O.R. procedure age 0-17
406,MDC 17P,Myeloprolif disord or poorly DIFF NEOPL W MAJ O.R.PROC W CC
407,MDC 17P,Myeloprolif disord or poorly diff neopl w maj o.r.proc w/o cc
408,MDC 17P,Myeloprolif disord or poorly diff neopl w other o.r.proc
409,MDC 17M,Radiotherapy
410,MDC 17M,Chemotherapy w/o acute leukemia as secondary diagnosis
411,MDC 17M,History of malignancy w/o endoscopy
412,MDC 17M,History of malignancy w endoscopy
413,MDC 17M,Other myeloprolif dis or poorly diff neopl diag W CC
414,MDC 17M,Other myeloprolif dis or poorly diff neopl diag W/O CC
415,MDC 18P,O.R. Procedure for infectious & parasitic diseases
416,MDC 18M,Septicemia age>17
417,MDC 18M,Septicemia age 0-17
418,MDC 18M,Postoperative & post-traumatic infections
419,MDC 18M,Fever of unknown origin age>17 W CC
420,MDC 18M,Fever of unknown origin age>17 W/O CC
421,MDC 18M,Viral illness age>17
422,MDC 18M,Viral illness & fever of unknown origin age 0-17
423,MDC 18M,Other infectious & parasitic diseases diagnoses
424,MDC 19P,O.R. Procedure W principal diagnoses of mental illness
425,MDC 19M,Acute adjust react & disturbances of psychosocial dysfunction
426,MDC 19M,Depressive neuroses
427,MDC 19M,Neuroses except depressive
428,MDC 19M,Disorders of personality & impulse control
429,MDC 19M,Organic disturbances & mental retardation
430,MDC 19M,Psychoses
431,MDC 19M,Childhood mental disorders
432,MDC 19M,Other mental disorder diagnoses
433,MDC 20M,Alcohol/drug abuse or dependence, left AMA
434,MDC 20M,Alc/drug abuse or depend, detox or oth sympt treat W CC
435,MDC 20M,Alc/drug abuse or depend, detox or oth sympt treat W/O CC
436,MDC 20M,ALC/Drug dependence w rehabilitation therapy
437,MDC 20M,ALC/Drug dependence, combined rehab & detox therapy
439,MDC 21P,Skin grafts for injuries
440,MDC 21P,Wound debridements for injuries
441,MDC 21P,Hand procedures for injuries
442,MDC 21P,Other O.R. procedures for injuries w cc
443,MDC 21P,Other O.R. procedures for injuries w/o cc
444,MDC 21M,Traumatic injury age>17 w cc
445,MDC 21M,Traumatic injury age>17 w/o cc
446,MDC 21M,Traumatic injury age 0-17
447,MDC 21M,Allergic reactions age>17
448,MDC 21M,Allergic reactions age 0-17
449,MDC 21M,Poisoning & toxic effects of drugs age>17 w cc
450,MDC 21M,Poisoning & toxic effects of drugs age>17 w/o cc
451,MDC 21M,Poisoning & toxic effects of drugs age 0-17
452,MDC 21M,Complications of treatment w cc
453,MDC 21M,Complications of treatment w/o cc
454,MDC 21M,Other injury, poisoning & toxic effect diag w cc
455,MDC 21M,Other injury, poisoning & toxic effect diag w/o cc
456,MDC 22M,Burns, transferred to another acute care facility
457,MDC 22M,Extensive burns w/o O.R. procedure
458,MDC 22P,Non-extensive burns w skin graft
459,MDC 22P,Non-extensive burns w wound debridement or other O.R. proc
460,MDC 22M,Non-extensive burns w/o O.R. procedure
461,MDC 23P,O.R. proc w Diagnoses of other contact w health services
462,MDC 23M,Rehabilitation
463,MDC 23M,Signs & symptoms w cc
464,MDC 23M,Signs & symptoms w/o cc
465,MDC 23M,Aftercare w history of malignancy as secondary diagnosis
466,MDC 23M,Aftercare w/o history of malignancy as secondary diagnosis
467,MDC 23M,Other factors influencing health status
468, P,Extensive O.R. procedure unrelated to principal diagnosis
469, Principal diagnosis invalid as discharge diagnosis
470, Ungroupable
471,MDC 08P,Bilateral or multiple major joint procs of lower extremity
472,MDC 22P,Extensive burns w O.R. procedure
473,MDC 17M,Acute leukemia w/o major O.R. procedure age>17
475,MDC 04M,Respiratory system diagnosis with ventilator support
476, P,Prostatic O.R. procedure unrelated to principal diagnosis
477, P,Non-extensive O.R. procedure unrelated to principal diagnosis
478,MDC 05P,Other vascular procedures w cc
479,MDC 05P,Other vascular procedures w/o cc
480, P,Liver transplant
481, P,Bone marrow transplant
482,P,Tracheostomy for face,mouth & neck diagnoses
483,P,Tracheostomy except for face,mouth & neck diagnoses
484,MDC 24P,Craniotomy for multiple significant trauma
485,MDC 24P,Limb reattachment, hip and femur proc for multiple significant trauma
486,MDC 24P,Other O.R. procedures for multiple significant trauma
487,MDC 24M,Other multiple significant trauma
488,MDC 25P,HIV w Extensive O.R. procedure
489,MDC 25M,HIV w Major related condition
490,MDC 25M,HIV w or w/o Other related condition
491,MDC 08P,Major joint & limb reattachment procedures of upper extremity
492,MDC 17M,Chemotherapy w acute leukemia as secondary diagnosis
493,MDC 07P,Laparoscopic cholecystectomy w/o C.D.E. w cc
494,MDC 07P,Laparoscopic cholecystectomy w/o C.D.E. w/o cc
495,P,Lung transplant
496,MDC 08P,Combined anterior/posterior spinal fusion
497,MDC 08P,Spinal fusion w cc
498,MDC 08P,Spinal fusion w/o cc
499,MDC 08P,Back & neck procedures except spinal fusion w cc
500,MDC 08P,Back & neck procedures except spinal fusion w/o cc
501,MDC 08P,Knee procedures w PDX of infection w cc
502,MDC 08P,Knee procedures w PDX of infection w/o cc
503,MDC 08P,Knee procedures w/o PDX of infection
892, MDC 15,Extreme immaturity or respiratory distress syndrome, neonate, with ICD-9-CM code 765.0
893, MDC 15, Extreme immaturity or respiratory distress syndrome, neonate, without ICD-9-CM code 765.0, in a level I or II nursery
894, MDC 15, Extreme immaturity or respiratory distress syndrome, neonate, without ICD-9-CM code 765.0, in a level III nursery
895, MDC 15, Prematurity with major problems, with birthweight <<or=1750 grams, in level I or II nursery
896, MDC 15, Prematurity with major problems, with birthweight <<or=1750 grams, in level III nursery
897, MDC, 15, Prematurity with major problems, with birthweight > 1750 grams, in level I or II nursery
898, MDC 15, Prematurity with major problems, with birthweight > 1750 grams, in level III nursery
Eff 10-1-84; 7-1-85; 7-3-86; 10-19-87; 6-30-89 (Emer.); 7-21-89; 7-1-90; 9-3-91 (Emer.); 11-10-91; 7-1-92; 1-20-95; 2-1-00; 8-1-02
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01 , 5111.02
R.C. 119.032 review dates: 5/9/2002 and 08/01/2007

5160-2-07.12 Appeals and reconsideration of departmental determinations regarding hospital inpatient and outpatient services.

(A) General.

Pursuant to rules 5101:3-1-57 and 5101:6-50-01 of the Administrative Code, hospitals may appeal under Chapter 119. of the Revised Code final settlements that are based upon final audits by the department. Rule 5101:3-2-24 of the Administrative Code describes of final fiscal audits and final settlements performed by the department. Rules 5101:3-1-29 and 5101:3-1-27 of the Administrative Code describe the audits performed by the department's of surveillance and utilization review section, which are also 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 5101:3-2-07.13 of the Administrative Code, the department or a medical review entity under contract to the department may make determinations regarding utilization review in accordance with the standards set forth in rules 5101:3-2-02, 5101:3-2-07.9, 5101:3-2- 07.13, and 5101:3-2-40 of the Administrative Code. These determinations are subject to the reconsideration process described in rule 5101:3-1-57 of the Administrative Code as follows:

(1) A written request for a reconsideration must be submitted to the department or the medical review entity, whichever made the initial determination, within sixty days of the date of the determination. The department or the medical review entity shall have thirty working days from receipt of the request for reconsideration to issue a written 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; and

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

(2) The department will conduct an administrative review of the reconsideration decision if the provider submits its request within thirty days of that decision. The department shall have thirty working 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.

(3) The department may extend time frames described in paragraphs (B)(1) and (B)(2) 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)(2) 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 inpatient hospital payments.

(1) Except when the department's determination is based on a finding made by medicare, the proper application of rules 5101:3-2-07.1 and 5101:3-2-07.2 of the Administrative Code and the proper calculation of amounts(including source data used to calculate the amounts) determined in accordance with rules 5101:3-2-07.4, 5101:3-2-07.6, and 5101:3-2-07.7 of the Administrative Code are subject to the reconsideration process described in rule 5101:3-1-57 of the Administrative Code as follows:

(a) Requests for reconsideration authorized by paragraph (C)(1) of this rule must 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 must be submitted within ninety 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 must be submitted within thirty days of the date the adjustment or determination was implemented. The request must 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 shall have thirty 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 must be submitted to the department in writing prior to final settlement as described rule 5101:3-2-24 of the Administrative Code and within thirty 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 must include all documentation that explains the appeal decision. The department shall have thirty days in which to notify the provider of its final and binding decision regarding the medicare audit finding.

(3) Reconsideration may also be requested if a hospital believes that a claim or claims were paid in error because of an incorrect DRG (diagnosis related groups) assignment or incorrect payment calculation. In such an instance, the hospital must resubmit the claim(s) for an adjustment as described in rule 5101:3-1-19.8 of the Administrative Code. Following the adjustment process, if the hospital continues to believe that the department's DRG assignment or payment calculation was in error, the provider may submit a written request for reconsideration that includes all documentation supporting the providers position. In this instance, the department shall have sixty days in which to notify the provider of its final and binding decision.

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

Any recipient whose claim for inpatient 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 5101:3-2-07.9 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 DRG classification system and the method of classification of discharges within DRGs.

(2) The assignment of relative weights to DRGs based on the methodology set forth in rule 5101:3-2-07.3 of the Administrative Code.

(3) The establishment of peer groups as set forth in rule 5101:3-2-07.2 of the Administrative Code.

(4) The methodology used to determine prospective payment rates as described in rules 5101:3-2-07.4 and 5101:3-2-07.6 to 5101:3-2-07.8 of the Administrative Code.

(5) The methodology used to identify cost and day thresholds for services that may qualify for outlier payments as described in rule 5101:3-2-07.9 of the Administrative Code.

(6) The formulas used to determine rates of payment for outliers, certain transfers and readmissions, and services subject to preadmission certification, as described, respectively, in rules 5101:3-2-07.9, 5101:3-2-07.11, and 5101:3-2-40 of the Administrative Code.

(7) The peer group average cost per discharge for all hospitals except when the conditions detailed in rule 5101:3-2-07.8 of the Administrative Code are met.

(8) Statewide calculations of the direct and indirect medical education threshold for allowable costs per intern and resident as described in rule 5101:3-2-07.7 of the Administrative Code and of the threshold for establishing which hospitals will be recognized as providing a disproportionate share of indigent care as described in rule 5101:3-2-07.5 of the Administrative Code.

Effective: 05/01/2007
R.C. 119.032 review dates: 01/02/2007 and 05/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 10/11/84, 7/1/85, 7/3/86, 10/19/87, 7/1/90, 7/1/92, 11/17/92 (Emer), 2/1/93, 8/1/02

5160-2-07.13 Utilization control.

(A) The Ohio department of job and family services shall perform or shall require a medical review entity to perform utilization review for medicaid inpatient services regardless of the payment methodology used for reimbursement of those services. The nature of this program is described in paragraphs (A) to (E) of this rule. Utilization review of outpatient hospital services is described in paragraph (F) of this rule. For the purposes of this rule, "ODJFS" means ODJFS or its contractual designee. ODJFS, during the course of its analyses, may request information or records from the hospital and may conduct on-site medical record reviews. Reviews shall be completed within twelve months of the payment date and in the case of interim payments described in rule 5101:3-2-07.11 of the Administrative Code within twelve months after the last payment has been made. Paragraphs (C) to (D)(3) of this rule provide examples of reviews to be completed by ODJFS.

(B) ODJFS shall review a minimum of two per cent of all admissions retrospectively. Admissions selected for review will be drawn from several categories including but not limited to those identified in paragraphs (C)(1) to (D)(3) of this rule.

(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 5101:3-2-02 of the Administrative Code; to determine whether the discharge occurred at a medically appropriate time, to assess the quality of care rendered as described in 42 C.F.R. 456.3(b) , and to assess compliance with division 5101:3 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 ODJFS may deny payment or recoup payment beginning with the first inappropriate admission and/or discharge. Any negative determinations must be made by a physician.

(3) If the diagnostic and/or procedural information on the claim form 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.

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

(1) ODJFS may review transfers as defined in rule 5101:3-2-02 of the Administrative Code. The purpose of the transfer review will be to examine the documented reasons for and appropriateness of the transfer. ODJFS considers a transfer as appropriate if the transfer is required because the individual requires some treatment or care which that is unavailable at the transferring hospital or if there are other exceptional circumstances that justify transfer. Because this provision addresses exceptional cases, it is impossible to delineate exact criteria to cover all possible circumstances. Cases will be individually considered by ODJFS based on the merits of each case. If any of the hospital's transfer cases reviewed are found to be inappropriate transfers, then ODJFS may intensify the review, including the addition of prepayment review and pretransfer certification. ODJFS may deny payment to or recoup payment from a provider who has transferred patients inappropriately.

(2) ODJFS may review readmissions as readmissions are defined in rule 5101:3-2-02 of the Administrative Code. The purpose of readmission review is to determine if the readmission is appropriate. If the readmission is related to the first hospitalization, ODJFS will determine if the readmission resulted from complications or other circumstances that arose because of an early discharge and/or other treatment errors. If the readmission is unrelated, ODJFS will determine if the treatment or care provided during the readmission should have been provided during the first hospitalization. If it is determined the readmission was inappropriate, 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) ODJFS 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 the physician, 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 5101:3-2-02 and 5101:3-2-03 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) ODJFS 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 5101:3-2-21 of the Administrative Code.

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

(D) ODJFS 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 .

(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, ODJFS may correct the claim information and recalculate payment based on the appropriate DRG assignment. If the recalculation shows an overpayment was made to the hospital, the overpayment will be reconciled as an adjustment to the claim. In all instances, the information found in the medical record when used in conjunction with the physician attestation is controlling.

(E) Pre-certification review as detailed in rule 5101:3-2-40 of the Administrative Code shall be conducted in addition to the utilization review activities described in this rule.

(F) Outpatient hospital services may also be reviewed by ODJFS to determine whether the care or services were medically necessary as defined in rule 5101:3-2-02 of the Administrative Code, to determine whether the services were appropriately billed, and to assess the quality of care rendered as described in 42 C.F.R. 456.3(b) .

(G) Intensified reviews may result whenever ODJFS identifies inappropriate admission or billing practices during reviews conducted in accordance with this rule.

(H) Medical records must be maintained in accordance with 42 C.F.R. 482.24 . Records requested by ODJFS for review must be supplied within thirty days of the request as described in rule 5101:3-1-17.2 of the Administrative Code. Failure to produce records within thirty days shall result in withholding or recoupment of medicaid payments.

(I) 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 5101:3-2-07.12 of the Administrative Code.

(J) ODJFS has delegated to the Ohio department of mental health (ODMH) the authority to make determinations regarding utilization review for inpatient psychiatric services in accordance with paragraphs (B), (C), (D), and (E) of this rule.

Effective: 05/01/2007
R.C. 119.032 review dates: 01/02/2007 and 05/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 10/1/84, 7/1/85, 7/3/86, 10/19/87, 4/1/88, 7/1/90, 9/3/91 (Emer), 11/10/91, 7/1/92, 12/29/95 (Emer), 3/16/96, 12/15/96, 8/1/02

5160-2-07.17 Provision of basic, medically necessary hospital-level services.

Under the provisions of section 5112.17 of the Revised Code, each hospital that receives payment under the provisions of Chapter 5112. of the Revised Code, shall 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. Current recipients of the disability assistance (DA) program as defined in Chapter 5115. of the Revised Code or its successor program, qualify for services under the provisions of this rule.

(A) Definitions.

(1) "Basic, medically necessary hospital level services" are defined as all inpatient and outpatient services covered under the medicaid program in Chapter 5101:3-2 of the Administrative Code with the exception of transplantation services and services associated with transplantation. These covered services must be ordered by an Ohio licensed physician and delivered at a hospital where the physician 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/or 5119. of the Revised Code. Hospitals will be responsible for providing basic, medically necessary hospital-level services to those persons described in paragraph (B) of this rule.

(2) "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.

(B) Determination of eligibility. A person is eligible for basic, medically necessary hospital-level services under the provisions of this rule if the person is a current recipient of the disability assistance(DA) program or its successor program, or the person's individual or family income is at or below the current poverty guideline issued by the department of health and human services (available at: http://aspe.hhs.gov/poverty/figures-fed-reg.shtml), that applies to the individual or family when calculated by either of the methods described in paragraphs (B)(2)(a) and (B)(2)(b) of this rule on the date these services were provided.

(1) For purposes of this rule, a "family" shall include 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" shall 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 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 shall proceed with the available income information. If the patient is the child of a minor parent who still resides in the home of the patient's grandparents, the "family" shall include only the parent(s) and any of the parent(s)' children, natural or adoptive who reside in the home.

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

(a) Multiplying by four the person's or family's income, 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 must be determined separately for each admission, unless the patient is readmitted within forty-five days of discharge for the same underlying condition. Eligibility for recipients of the disability assistance (DA)program or its successor program must be verified on a monthly basis.

(4) A complete application for the hospital care assurance program is required prior to determination of eligibility. Each hospital shall develop an application that, at a minimum, must document income, family size and eligibility for the Medicaid program. The patient or a legal representative is required 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 it and must document why the patient is unable to sign the application.

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

(6) Applicants shall 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.

(7) Nothing in this rule shall be construed to prevent a hospital from requiring an individual to apply for eligibility under the medical assistance program before the hospital processes an application under this rule.

(C) Billing requirements. Hospitals may bill any third-party payer that has a legal liability to pay for services rendered under the provisions of this rule. Hospitals may bill the medicaid program in accordance with Chapter 5111. of the Revised Code and the rules adopted under that chapter for services rendered under the provisions of this rule if the individual becomes a recipient of the medicaid program. Hospitals may bill individuals for services if all of the following apply:

(1) The hospital has an established post-billing procedure for determining the individual's income and canceling the charges if the individual is found to qualify for services under the provisions of this rule;

(2) The initial bill, and at least the first follow-up bill is accompanied by a written statement that does all of the following:

(a) Explains that individuals with income at or below the federal poverty guidelines are eligible for services without charge;

(b) Specifies the federal poverty guideline for individuals and families of various sizes at the time the bill is sent; and

(c) Describes the procedure required by paragraph (C)(1) of this rule.

(3) If the written statement as described in paragraph (C)(2) of this rule is printed on the back of the hospital's bill or data-mailer, the hospital must reference the statement on the front of the bill or data-mailer.

(4) Notwithstanding paragraph (B) of this rule, a hospital providing care to an individual under the provisions of this rule is subrogated to the rights of any individual to receive compensation or benefits from any person or governmental entity for the hospital goods and services rendered.

(D) Notice requirements.

Each hospital that receives payment under Chapter 5112. of the Revised Code shall post notices in appropriate areas in the facility, including but not limited to the admissions areas, the business office and the emergency room that 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 must contain the following in order to comply with the requirement as described in this paragraph:

(1) At a minimum, the posted notices must specify the rights of these individuals to receive without charge, basic, medically necessary hospital-level services;

(2) The wording of the posted notice must be clear and in simple terms understandable by the population serviced;

(3) Posted notice must be printed in English and other languages that are common to the population of the area serviced;

(4) The posted notice must be clearly readable at a distance of twenty feet or the expected vantage point of the patrons;

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

(E) Documentation Requirements.

Each hospital shall 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 5101:3-2-23 of the Administrative code. Each hospital may change its written policy as needed, but policy changes may not be implemented retroactively. The written policy shall 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 (B) of this rule,

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

(F) Reporting requirements.

Each hospital shall collect and report to the department information on the number and categorical identity of persons served under the provisions of this rule.

(1) This information will be reported on the JFS 02930, schedule F which must be submitted annually along with a certification of the accuracy of this reported data as required by 5101:3-2-23 of the Administrative Code. The JFS 02930 and instructions for completion are located in appendix A of rule 5101:3-2-23 of the Administrative Code.

(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 patients charges on patient accounts is not permitted.

(3) Each hospital shall maintain, make available for department review and provide to the department on request, any records necessary to document its compliance with the provisions of this rule, including:

(a) Any documents, including medical records of population served, from which the information required to be reported on the JFS 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 (B) of this rule.

(d) A copy of the disability assistance card or other evidence of eligibility for any person who is a recipient of the disability assistance (DA) program or its successor program at the time the services defined in paragraph (A) of this rule were delivered.

(4) Hospitals must 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.

(G) 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.

R.C. 119.032 review dates: 12/22/2010 and 12/22/2015
Promulgated Under: 119.03
Statutory Authority: 5112.03
Rule Amplifies: 5112.03 , 5112.17
Prior Effective Dates: 5/22/92 (Emer), 8/20/92, 2/1/93, 7/16/93 (Emer), 9/30/93, 10/1/93 (Emer), 12/30/93, 1/20/95, 3/16/96, 5/22/97, 12/14/00, 1/1/06

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

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 5112.01 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 5101:3-2-07.5 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 5112.01 of the Revised Code.

(4) "Hospital care assurance program fund" means the fund described under section 5112.18 of the Revised Code.

(5) "Hospital care assurance match fund" means the fund described under section 5112.18 of the Revised Code.

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

(7) "Legislative budget services fund" means the fund described under section 5112.19 of the Revised Code.

(8) "Health care services administration fund" means the fund described under section 5111.94 of the Revised Code.

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

(10) "Total facility costs" for each hospital means the amount from the JFS 02930, "Hospital Cost Report", for the applicable state fiscal year, schedule B, column 3, line 101. For non-medicaid participating hospitals, total facility costs shall be determined from the medicare cost report.

(11) "Total skilled nursing facility costs" for each hospital means the amount on the JFS 02930, schedule B, column 3, line 34. For non-medicaid participating hospitals, total skilled nursing facility costs shall be determined from the medicare cost report.

(12) "Total home health facility costs" for each hospital means the amount on the JFS 02930, schedule B, column 3, line 67. For non-medicaid participating hospitals, total home health facility costs shall be determined from the medicare cost report.

(13) "Total hospice facility costs" for each hospital means the amount on JFS 02930, schedule B, column 3, line 68. For non-medicaid participating hospitals, total hospice facility costs shall be determined from the medicare cost report.

(14) "Total ambulance costs" for each hospital means the amount on JFS 02930, schedule B, column 3, line 64. For non-medicaid participating hospitals, total ambulance costs shall be determined from the medicare cost report.

(15) "Total Durable Medical Equipment (DME) rental costs" for each hospital means the amount on JFS 02930, schedule B, column 3, line 65. For non-medicaid participating hospitals, total DME rental costs shall be determined from the medicare cost report.

(16) "Total DME sold costs" for each hospital means the amount on JFS 02930, schedule B, column 3, line 66. For non-medicaid participating hospitals, total DME sold costs shall be determined from the medicare cost report.

(17) "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.

(18) "Adjusted total facility costs" means the result of subtracting the sum of the amounts defined in paragraphs (A)(11), (A)(12), (A)(13), (A)(14), (A)(15) and (A)(16) of this rule from the amount defined in paragraph (A)(10) 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 5101:3-2-23 of the Administrative Code that reflects the completed interim settled medicaid cost report(JFS 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 5101:3-2-23 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 (E) 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 legislative budget services fund.

From the first installment of the assessments paid under rule 5101:3-2-08.1 of the Administrative Code and intergovernmental transfers made under rule 5101:3-2-08.1 of the Administrative Code during each program year beginning in an odd-numbered calendar year, the department shall deposit into the state treasury to the credit of the legislative budget services fund a total amount equal to the amount by which the biennial appropriation from that fund exceeds the amount of the unexpended, unencumbered monies in that fund.

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

From the first installment of assessments paid under rule 5101:3-2-08.1 of the Administrative Code and intergovernmental transfers made under rule 5101:3-2-08.1 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 5112.06 of the Revised Code and intergovernmental transfers made under section 5112.07 of the Revised Code during each program year.

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

During each program year, the department may mail any data the department may choose to use for disproportionate share and indigent care adjustments, described in rule 5101:3-2-09 of the Administrative Code to each hospital. Not later than thirty days after the department mails the data, 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, upon 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 (E)(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)(15) 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)(8) 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.

(F) Confidentiality.

Except as specifically required by the provisions of this rule and rule 5101:3-2-24 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 job and family services or by any person under contract with the department who has access to such information.

Effective: 12/25/2010
R.C. 119.032 review dates: 09/23/2010 and 12/01/2015
Promulgated Under: 119.03
Statutory Authority: 5112.03
Rule Amplifies: 5112.03
Prior Effective Dates: 7/1/94, 2/27/95 (Emer), 5/18/95, 6/26/96 (Emer), 8/13/96, 7/24/97 (Emer), 8/21/97 (Emer), 11/1/97, 6/26/98 (Emer), 9/1/98, 4/16/99 (Emer), 6/10/99 (Emer), 8/26/99, 7/16/00 (Emer), 7/18/00 (Emer), 9/28/00 (Emer), 8/2/01, 7/1/02 (Emer), 9/19/02, 7/28/03, 7/22/05

5160-2-08.1 Assessment rates.

The provisions of this rule are applicable for the program year(s) specified in this rule for all hospitals as defined under section 5168.01 of the Revised Code.

(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 5168.01 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) The program years to which this rule applies are identified in paragraphs (B)(1) and (B)(2) of this rule. When the department is notified by the centers for medicare and medicaid services that an additional disproportionate share allotment is available for a prior program year, the department may amend the assessment rates for the prior program year.

(1) The assessment rates applicable to the program year that ends in calendar year 2013 are specified in paragraph (C) of this rule.

(2) The revised assessment rates applicable to the program year that ends in calendar year 2012 are specified in paragraph (D) of this rule.

(C) Calculation of assessment amounts.

The calculations described in this rule will be based on 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)(18) of rule 5160-2-08 of the Administrative Code.

(2) For hospitals with adjusted total facility costs, as described in paragraph (C)(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 (C)(1) of this rule by 0.0083584. The product will be each hospital's assessment amount. For hospitals with adjusted total facility costs, as described in paragraph (C)(1) of this rule, that are greater than $216,372,500, multiply a factor of 0.0083584 times the hospital's adjusted total facility costs as described in paragraph (C)(1) of this rule, up to $216,372,500. Multiply a factor of 0.00665 times the hospital's adjusted total facility costs as described in paragraph (C)(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 (C)(2) of this rule are subject to adjustment under the provisions of paragraph (F) of this rule.

(D) For the program year specified in paragraph (B)(2) of this rule, the assessment rates specified in rule 5160-2- 08.1 of the Administrative Code, effective February 21, 2013 are revised in paragraphs (D)(1) to (D)(3) of this rule.

(1) The original adjusted total facility cost threshold of $216,372,500 is unchanged.

(2) The original tier one assessment rate of 0.0083966197575 is increased to 0.0084222.

(3) The original tier two assessment rate of 0.006 is unchanged.

(E) 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.

(F) Notification and reconsideration procedures.

(1) The department shall mail by certified mail, return receipt requested, the results of the determinations made under paragraph (C) of this rule to each hospital. If no hospital submits a request for reconsideration as described in 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 paragraph (C) of this rule, any hospital may submit to the department a written request for reconsideration of the preliminary determination made under paragraph (C) 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 paragraph (C) of this rule or adjust the amount of the intergovernmental transfers required under paragraph (E) 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.

Effective: 01/01/2014
R.C. 119.032 review dates: 12/01/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02 , 5168.02 , 5168.06
Rule Amplifies: 5164.02 , 5168.02 , 5168.06
Prior Effective Dates: 7/1/94, 2/27/95 (Emer), 5/18/95, 6/26/96 (Emer), 8/13/96, 7/24/97 (Emer), 8/21/97 (Emer), 11/1/97, 6/26/98 (Emer), 9/1/98, 4/16/99 (Emer), 6/10/99 (Emer), 8/26/99, 7/16/00 (Emer), 7/18/00 (Emer), 9/28/00, 8/2/01, 7/1/02 (Emer), 9/19/02, 7/28/03, 7/1/04, 7/22/05, 10/27/06 (Emer), 11/30/06, 9/17/07, 8/3/08, 8/13/09, 12/25/10, 9/29/11 (Emer), 12/28/11, 11/28/12 (Emer.), 2/21/13

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

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 5112.01 of the Revised Code.

(A) Definitions.

(1) "Total medicaid costs" for each hospital means the sum of the amounts reported in JFS 02930, for the applicable state fiscal year, schedule H, section I, columns 1 and 3, line 1 and section II, column 1, line 10.

(2) "Total medicaid managed care plan inpatient costs" for each hospital means the amount on JFS 02930 schedule I, column 3, line 101.

(3) "Total medicaid managed care plan outpatient costs" for each hospital means the amount on JFS 02930 schedule I, column 5, line 101.

(4) "Total Title V costs" for each hospital means the amount on JFS 02930, schedule H, section I, column 2, line 1 and section II, column 2, line 10.

(5) "Total inpatient disability assistance medical costs" for each hospital means the amount on the JFS 02930, schedule F, columns 4 and 5, line 8.

(6) "Total inpatient uncompensated care costs under one hundred per cent" for each hospital means the amount on the JFS 02930, schedule F, columns 4 and 5, line 9.

(7) "Total inpatient uncompensated care costs above one hundred per cent without insurance" for each hospital means the amount on the JFS 02930, schedule F, column 5, line 10.

(8) "Total outpatient disability assistance medical costs" for each hospital means the amount on the JFS 02930, schedule F, columns 4 and 5, line 12.

(9) "Total outpatient uncompensated care costs under one hundred per cent" for each hospital means the amount on the JFS 02930, schedule F, columns 4 and 5, line 13.

(10) "Total outpatient uncompensated care costs above one hundred per cent without insurance" for each hospital means the amount on the JFS 02930, schedule F, column 5, line 14.

(11) "Total disability assistance medical costs" means the sum of total inpatient disability assistance costs as described in paragraph (A)(5) of this rule, and total outpatient disability assistance costs as described in paragraph (A)(8) of this rule.

(12) "Total uncompensated care costs under one hundred per cent" 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)(9) of this rule.

(13) "Total uncompensated care costs above one hundred per cent without insurance" 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)(10) of this rule.

(14) "Managed care plan days" (MCP days) means for each hospital the amount on the JFS 02930, schedule I, column 2, line 103.

(15) "High federal disproportionate share hospital" means a hospital with a ratio of total medicaid days plus MCP days to total facility days greater than the statewide mean ratio of the sum of total medicaid days plus MCP days to total facility days plus one standard deviation.

(16) "Total medicaid payments" for each hospital means the sum of the amounts reported on the JFS 02930, schedule H, column 1, lines 7, 15, 26, and column 3, lines 7 and 26.

(17) "Total medicaid days" means for each hospital the amount on the JFS 02930, schedule C, column 6, line 35 and column 10, line 35.

(18) "Total facility days" means for each hospital the amount reported on the JFS 02930, schedule C, column 4, line 35.

(19) "Medicaid inpatient payment-to-cost ratio" for each hospital means the sum of the amounts reported on the JFS 02930, schedule H, columns 1 and 3, line 7, less the amount described in paragraph (A)(30) of this rule, divided by the sum of the amounts reported on the JFS 02930, schedule H, section I, columns 1 and 3, line 1.

(20) "Medicaid outpatient payment-to-cost ratio" for each hospital means the amount reported on the JFS 02930, schedule H, column 1, line 15, divided by the amount reported on the JFS 02930, schedule H, section II, column 1, line 10.

(21) "Total medicaid managed care plan (MCP) costs" means the actual cost to the hospital of care rendered to medical assistance recipients enrolled in a managed care plan that has entered into a contract with the department of job and family services and is the amount on JFS 02930, schedule I, column 3, line 101 and column 5, line 101.

In the event the hospital cannot identify the costs associated with recipients enrolled in a health maintenance organization, the department shall add the payments made or charges incurred for the recipient, as reported by the health maintenance organization and verified by the department, to total medicaid managed care costs.

(22) "Medicaid managed care plan (MCP) inpatient payments" for each hospital means the amount on JFS 02930 schedule I, column 2, line 107.

(23) "Medicaid managed care plan (MCP) outpatient payments" for each hospital means the amount on JFS 02930 schedule I, column 4, line 107.

(24) "Total medicaid managed care plan (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" means the amount described in paragraph (A) of rule 5101:3-2-08 of the Administrative Code.

(26) "Rural Access Hospital (RAH)" means a hospital that is classified as a rural hospital 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 job and family services of such certification. Beginning in the program year that ends in calendar year 2004, the Ohio department of job and family services 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 job and family services of any change in their critical access hospital status, including continued CAH designations, immediately following notification from CMS.

(28) "Hospital-specific disproportionate share limit" means the limit on disproportionate share and indigent care payments made to hospitals as defined in paragraph (D) of rule 5101:3-2-07.5 of the Administrative Code.

(29) "Children's hospitals" are those hospitals that meet the definition in paragraph (A)(2) of rule 5101:3-2-07.2 of the Administrative Code

(30) "Other medicaid payments" for each hospital means the amount reported in JFS 02930, schedule H, section I, column 1, line 5.

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

(B) Applicability.

The requirements of this rule apply as long as CMS determines that the assessment imposed under section 5112.06 of the Revised Code is a permissible health care related tax. Whenever the department of job and family services 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 5101:3-2-08 of the Administrative Code.

(2) For new hospitals, the first available cost report filed with the department in accordance with rule 5101:3-2-23 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 5101:3-2-08 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 5101:3-2-08 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 5101:3-2-08 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 assessments deposited into the legislative budget services fund and the health care services administration fund described in rule 5101:3-2-08 of the Administrative Code.

(b) The total amount of intergovernmental transfers required to be made by governmental hospitals less the amount of transfers deposited into the legislative budget services fund and the health care services administration fund described in rule 5101:3-2-08 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 United States center for medicare and medicaid services (CMS) for that program year.

(2) The funds available in the indigent care pool shall be distributed through policy payment pools in 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)(f) of this rule.

(a) High federal disproportionate share hospital pool: 7.85 per cent.

(b) Medicaid indigent care pool: 20.40 per cent.

(c) Disability assistance medical and uncompensated care pool below one hundred per cent of poverty: 61.12 per cent.

(d) Uncompensated care for persons above one hundred per cent of poverty: 5.24 per cent.

(e) Critical access and rural hospitals: 4.06 per cent.

(f) Children's hospitals: 1.33 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)(15) 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 medicaid costs and total medicaid MCP costs to the sum of total 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) If any hospital is limited as described in paragraph (E)(1)(b)(i) 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 funds for this pool are expended.

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

(a) For each hospital, calculate medicaid shortfall by subtracting from total medicaid costs, as defined in paragraph (A)(1) of this rule, the total medicaid payments, as defined in paragraph (A)(16) of this rule. For hospitals with a negative medicaid shortfall, the medicaid shortfall amount is equal to zero.

(b) For each hospital, calculate medicaid MCP inpatient shortfall by subtracting from the total medicaid managed care plan inpatient costs, as defined in paragraph (A)(2) of this rule, medicaid MCP inpatient payments, as defined in paragraph (A)(22) of this rule.

(c) For each hospital, calculate medicaid MCP outpatient shortfall by subtracting from the total medicaid managed care plan outpatient costs, as defined in paragraph (A)(3) of this rule, medicaid MCP outpatient payments, as defined in paragraph (A)(23) of this rule.

(d) For each hospital, calculate medicaid MCP shortfall as the sum of the amount calculated in paragraph (E)(2)(b) of this rule, and the amount calculated in paragraph (E)(2)(c) of this rule.

(e) For each hospital, sum the hospital's medicaid shortfall as calculated in paragraph (E)(2)(a) of this rule, medicaid MCP shortfall as calculated in paragraph (E)(2)(d) of this rule, total medicaid costs, total medicaid MCP costs, and total Title V costs.

(f) For all hospitals, sum all hospitals medicaid shortfall as calculated in paragraph (E)(2)(a) of this rule, medicaid MCP shortfall as calculated in paragraph (E)(2)(d) of this rule, total medicaid costs, total medicaid MCP costs, and total Title V costs.

(g) For each hospital, calculate the ratio of the amount in paragraph (E)(2)(e) of this rule to the amount in paragraph (E)(2)(f) of this rule.

(h) For each hospital, multiply the ratio calculated in paragraph (E)(2)(g) 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)(h) 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)(h) of this rule and any amount provided by paragraph (E)(2)(h)(iv) of this rule.

(iii) If the sum of a hospital's payment amounts calculated in paragraphs (E)(1) and (E)(2)(h) 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 amount calculated 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)(h)(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)(h) 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 funds for this pool are expended.

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

(3) Hospitals shall receive funds from the disability assistance medical and uncompensated care indigent care payment pool.

(a) For each hospital, sum total disability assistance medical costs defined in paragraph (A)(11) of this rule and total uncompensated care costs under one hundred per cent defined in paragraph (A)(12) of this rule. For hospitals with total negative disability assistance and 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 disability assistance medical and 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 disability assistance medical and 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 disability medical and 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 disability medical and 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 or all unlimited hospitals have received one hundred per cent of the amount described in paragraph (E)(3)(a) of this rule.

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

(f) For each hospital except those meeting either condition described in paragraph (E)(3)(d)(i) or (E)(3)(d)(iii) of this rule, multiply a factor of 0.30 by the hospital's total uncompensated care costs above one hundred per cent without insurance, as described in paragraph (A)(13) of this rule. For hospitals meeting the conditions described in paragraph (E)(3)(d)(i) or (E)(3)(d)(iii) of this rule, multiply the hospital's total uncompensated care costs above one hundred per cent by zero.

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

(h) For each hospital, calculate the ratio of the amount in paragraph (E)(3)(f) of this rule to the amount in paragraph (E)(3)(g) of this rule.

(i) Subtract the amount calculated in paragraph (E)(3)(e) of this rule from the amount allocated in paragraph (D)(2)(c) of this rule and add the amount allocated in paragraph (D)(2)(d) of this rule.

(j) For each hospital, multiply the ratio calculated in paragraph (E)(3)(h) of this rule by the amount calculated in paragraph (E)(3)(i) of this rule to determine each hospital's uncompensated care above one hundred per cent without insurance payment, subject to the following limitations:

(i) If the sum of a hospital's payment amounts calculated in paragraphs (E)(1), (E)(2) and (E)(3)(d) 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 above one hundred per cent without insurance amount is equal to zero.

(ii) If the sum of a hospital's uncompensated care above one hundred per cent without insurance payment and the payment amounts calculated in paragraphs (E)(1), (E)(2), and (E)(3)(d) of this rule is less than the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule, then the hospital's uncompensated care above one hundred per cent without insurance payment is equal to the product of multiplying the ratio calculated in paragraph (E)(3)(h) of this rule by the amount calculated in paragraph (E)(3)(i) of this rule and any amount provided by paragraph (E)(3)(j)(iv) of this rule.

(iii) If the sum of a hospital's uncompensated care above one hundred per cent without insurance payment and the payment amounts calculated in paragraphs (E)(1), (E)(2), and (E)(3)(d) of this rule is greater than the hospital's disproportionate share limit defined in paragraph (A)(28) of this rule, then the hospital's uncompensated care above one hundred per cent without insurance payment is equal to the difference between the hospital's disproportionate share limit and the sum of the payment amounts calculated in paragraphs (E)(1), (E)(2), and (E)(3)(d) of this rule.

(iv) If any hospital is limited as described in paragraph (E)(3)(j)(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)(j) of this rule and sum these amounts for all limited hospital(s). Subtract the sum of the limited payments from the amount calculated in paragraph (E)(3)(i) of this rule and repeat the distribution described in paragraph the distribution described in paragraphs (E)(3)(g) to (E)(3)(j) of this rule until all funds for this pool are expended.

(k) For each hospital, sum the amount calculated in paragraph (E)(3)(d) of this rule, and the amount calculated in paragraph (E)(3)(j) of this rule. This amount is the hospital's disability assistance medical and 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 medicaid shortfall as described in paragraph (E)(2)(a) of this rule.

(b) For each hospital with CAH certification:

(i) Calculate the ratio of each CAH hospital's medicaid shortfall to total medicaid shortfall for all CAH hospitals.

(ii) For each CAH hospital, multiply the ratio calculated in paragraph (F)(1)(b)(i) of this rule by 32.01 per cent of the amount allocated in paragraph (D)(2)(e) 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 RAH 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 access hospital RAH payment pool.

(a) For each hospital with RAH 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)(h), and (E)(3)(k) of this rule.

(b) For each hospital with RAH 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 RAH 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 RAH 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)(e) of this rule.

(f) For each hospital with RAH 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 access 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 5101:3-2-08 and 5101:3-2-08.1 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 5101:3-2-08 and 5101:3-2-08.1 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, and the amount calculated in paragraph (E)(3)(f) 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)(d), (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, and the amount calculated in paragraph (E)(3)(f) 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)(d), (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 amount 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, 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, 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, multiply the ratio calculated in paragraph (H)(4) of this rule by the amount allocated in paragraph (D)(2)(f) 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)(d), (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)(f) 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 (J)(4) minus the sum of the lessor of each hospital's calculated payment amount calculated in (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 amount 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) Payments and adjustments.

(1) Every hospital that must make payments of assessments and/or intergovernmental transfers to the department of job and family services under the provisions of rule 5101:3-2-08.1 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 5101:3-2-08.1 of the Administrative Code, all payments of assessments and intergovernmental transfers, when applicable, from hospitals under rule 5101:3-2-08 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 (J)(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 5112.01 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 (J)(2) of this rule and the hospital care assurance match fund described in paragraph (J)(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 5101:3-2-08.1 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 5101:3-2-07.17 of the Administrative Code; and

(d) The payment made to hospitals does not exceed the hospital's disproportionate share limit as calculated in paragraph (D) of rule 5101:3-2-07.5 of the Administrative Code.

(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 (J)(6)(a) of this rule shall be made from the hospital care assurance program fund. Amounts recovered under paragraph (J)(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 (J)(6)(a) of this rule or the amount to be recovered from the hospital under paragraph (J)(6)(b) of this rule to the court of common pleas of Franklin county.

(K) Confidentiality.

Except as specifically required by the provisions of this rule and rule 5101:3-2-24 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 job and family services or by any person under contract with the department who has access to such information.

(L) 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 5101:3-2-23 of the Administrative Code on or before the dates specified in this rule and in rule 5101:3-2-23 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 job and family services on or before the dates specified in this rule or under any schedule for delayed payments established under paragraph (J)(1) of this rule shall be fined one thousand dollars for each day after the due date.

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

(M) 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 5101:3-2-08.1 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 day after the date on the warrant or electronic funds transfer (EFT) issued as payment by the department as described in paragraph (M)(2) of this rule.

(a) Beginning in the program year that ends in calendar year 2006, and each year thereafter, each hospital shall submit its assessment amount to the Ohio department of job and family services via electronic funds transfer.

(2) On or before the tenth 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 5101:3-2-08.1 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 (J)(7) of this rule.

Effective: 12/25/2010
R.C. 119.032 review dates: 08/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5112.03
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5112.01 , 5112.03 , 5112.04 , 5112.05 , 5112.06 , 5112.07 , 5112.08 , 5112.09 , 5112.10 , 5112.11 , 5112.17 , 5112.18 , 5112.19 , 5112.21
Prior Effective Dates: 5/16/94 (Emer), 7/24/94, 3/10/95, 3/16/96, 8/7/96 (Emer), 10/21/96, 11/1/97, 8/6/98 (Emer), 9/18/98 (Emer), 8/5/99 (Emer), 9/15/99 (Emer), 8/16/00 (Emer), 9/28/00, 8/2/01, 7/22/02, 7/28/03, 7/1/04, 10/1/04, 7/22/05, 10/27/06 (Emer), 11/30/06, 8/3/08, 8/13/09

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

This rule is applicable for each program year for all medicaid-participating psychiatric hospitals as described in paragraphs (B), (C), (D), (E) and (F) of rule 5101:3-2-01 of the Administrative Code.

(A) Definitions.

(1) "Inpatient days" means for each psychiatric hospital the number of inpatient hospital days as reported in JFS 02930, for the applicable state fiscal year, schedule C, column 4.

(2) "Insurance revenues" are reported on JFS 02930, schedule F, section II, column 1, line 24 and mean for each psychiatric hospital 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)(4) of this rule.

(3) "Medicaid inpatient utilization rate" means for each psychiatric hospital the ratio of the hospital's number of inpatient days attributable to patients who were eligible for medical assistance as described in paragraph (A)(6) of this rule divided by the hospital's total inpatient days as described in paragraph (A)(1) of this rule.

(4) "Self-pay revenues" means for each psychiatric hospital 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 as reported on JFS 02930, schedule F, column 2, line 24.

(5) "Total inpatient allowable costs" for each psychiatric hospital means the sum of the general service and capital related costs for inpatient hospital services reported in JFS 02930 schedule B, column 7.

(6) "Total medicaid days" for each psychiatric hospital means the sum of the amounts reported on JFS 02930, schedule F, section II, columns 6 and 8, line 24. For hospitals meeting the conditions set forth in paragraphs (E) and (F) of rule 5101:3-2-01 of the Administrative Code, total medicaid days means the sum of the amounts reported on JFS 02930, schedule F, section II, columns 6 to 8, line 24.

(7) "Total medicaid revenues" for each psychiatric hospital means the amount reported on JFS 02930, schedule H, section I, column 1, line 7.

(8) "Uncompensated care costs" means for each psychiatric hospital the total inpatient allowable costs as described in paragraph (A)(5) of this rule less total facility revenue as described in paragraph (A)(12) of this rule less the uncompensated care costs rendered to patients with insurance for the services provided as described in paragraph (A)(9) of this rule.

(9) "Uncompensated care costs rendered to patients with insurance" means 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 as reported on JFS 02930, schedule F, section II, column 5, line 24.

(10) "Charges for charity care" means for each psychiatric hospital the total charges for inpatient services provided to indigent patients as reported on JFS 02930, schedule F, section II, column 3, line 24. It includes charges for services provided to individuals who do not possess health insurance for the service provided. However, charity care does not include bad debts, contractual allowances or uncompensated care costs rendered to patients with insurance as described in paragraph (A)(9) of this rule.

(11) Except for free-standing, state-owned psychiatric hospitals, "Total charges for inpatient services" means for each psychiatric hospital the sum of the amounts reported for inpatient hospital services in JFS 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)(5) of this rule.

(12) "Total facility inpatient revenues" means for each psychiatric hospital the sum of the hospital's insurance revenues as described in paragraph (A)(2) of this rule, self-pay revenues as described in paragraph (A)(4) of this rule, and total medicaid revenues as described in paragraph (A)(7) of this rule.

(13) "Cash subsidies for inpatient services received directly from state and local governments" means for each psychiatric hospital the amount of cash subsidies each psychiatric hospital has received from state and local governments as reported on JFS 02930, schedule F, section II, column 4, line 24 and as reported by each hospital in accordance with paragraph (C) of this rule.

(B) Applicability.

The requirements of this rule are limited pursuant to section 1923 of the Social Security Act, 42 USC 1396r-4 .

(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 5101:3-2-08 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 either qualification described in paragraph (D)(1) or (D)(2) of this rule and meet the qualification in paragraph (D)(3) of this rule.

(1) The hospital's medicaid inpatient utilization rate, as described in paragraph (A)(3) of this rule, is at least one standard deviation above the mean medicaid inpatient utilization rate for all hospitals receiving medicaid payments in the state; or

(2) A low-income utilization rate in excess of twenty-five per cent, where the low-income utilization rate, the fraction expressed as a percentage, is the sum of:

(a) The sum of total medicaid revenues as described in paragraph (A)(7) of this rule, for inpatient services and cash subsidies for inpatient services received directly from state and local governments as described in paragraph (A)(13) of this rule, divided by the sum of total facility inpatient revenues as described in paragraph (A)(12) of this rule, and cash subsidies for inpatient services received directly from state and local governments as described in paragraph (A)(13) of this rule, plus

(b) Total charges for inpatient services for charity care as described in paragraph (A)(10) of this rule (less cash subsidies above, and not including contractual allowances and discounts other than for indigent patients ineligible for medicaid) divided by the total charges for inpatient services, as described in paragraph (A)(11) of this rule.

(3) A medicaid inpatient utilization rate as described in paragraph (A)(3) of this rule greater than or equal to one per cent.

(E) Determination of hospital disproportionate share groupings for payment distribution. Hospitals determined to be disproportionate share as described in paragraph (D) of this rule will be classified into one of three tiers based on data described in paragraph (C) of this rule. The groupings for payment distribution are described in paragraphs (E)(1) to (E)(3) of this rule.

(1) Tier one includes hospitals that meet the criteria in either paragraph (E)(1)(a) or (E)(1)(b) of this rule.

(a) Hospitals deemed to be disproportionate share hospitals based on a low-income utilization rate as described in paragraph (D)(2) of this rule greater than twenty-five per cent but less than forty per cent.

(b) Hospitals with a low-income utilization rate as described in paragraph (D)(2) of this rule less than or equal to twenty-five per cent that are deemed a disproportionate share hospital based on a medicaid inpatient utilization rate as described in paragraph (D)(1) of this rule.

(2) Tier two includes all hospitals deemed to be disproportionate share hospitals based on a low-income utilization rate as described in paragraph (D)(2) of this rule greater than or equal to forty per cent but less than fifty per cent.

(3) Tier three includes all hospitals deemed to be disproportionate share hospitals based on a low-income utilization rate as described in paragraph (D)(2) of this rule greater than or equal to fifty per cent.

(F) Distribution of funds within each hospital tier.

The funds available to each psychiatric hospital tier as described in paragraph (E) of this rule are distributed among the hospitals in each tier based on data described in paragraph (C) of this rule and according to the payment formulas described in paragraphs (F)(1) to (F)(3) of this rule.

(1) A maximum of ten per cent of the disproportionate share funds available to psychiatric hospitals as described in paragraph (H) of this rule will be distributed to the hospitals in tier one as described in paragraph (E)(1) of this rule according to the process described in paragraphs (F)(1)(a) to (F)(1)(f) of this rule.

(a) For each hospital in tier one, calculate the uncompensated care costs as described in paragraph (A)(8) of this rule.

(b) For all hospitals in tier one, sum all hospitals uncompensated care costs as described in paragraph (A)(8) of this rule.

(c) For each hospital in tier one, calculate the ratio of the amount described in paragraph (F)(1)(a) of this rule to the amount described in paragraph (F)(1)(b) of this rule.

(d) Multiply the ratio for each hospital calculated in paragraph (F)(1)(c) of this rule in tier one by the amount in paragraph (F)(1) of this rule to determine each hospital's disproportionate share payment amount.

(e) Each hospital will be distributed a payment amount based on the lesser of:

(i) Uncompensated care costs as determined in paragraph (A)(8) of this rule; or

(ii) The hospital's payment as determined in paragraph (F)(1)(d) of this rule.

(f) If no hospitals fall into tier one, or all funds are not distributed, then undistributed funds from tier one will be added to the funds available for distribution in tier three and be distributed in accordance with the process described in paragraphs (F)(3)(a) to (F)(3)(e) of this rule.

(2) A maximum of thirty per cent of the disproportionate share funds available to psychiatric hospitals as described in paragraph (H) of this rule will be distributed to the hospitals in tier two as described in paragraph (E)(2) of this rule according to the process described in paragraphs (F)(2)(a) to (F)(2)(f) of this rule.

(a) For each hospital in tier two, calculate the uncompensated care costs as described in paragraph (A)(8) of this rule.

(b) For all hospitals in tier two, sum all hospitals uncompensated care costs as described in paragraph (A)(8) of this rule.

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

(d) Multiply the ratio for each hospital calculated in paragraph (F)(2)(c) of this rule in tier two by the amount in paragraph (F)(2) of this rule to determine each hospital's disproportionate share payment amount.

(e) Each hospital will be distributed a payment amount based on the lesser of:

(i) Uncompensated care costs as determined in paragraph (A)(8) of this rule; or

(ii) The hospital's payment as determined in paragraph (F)(2)(d) of this rule.

(f) If no hospitals fall into tier two, or all funds are not distributed, then undistributed funds will be added to the funds available for distribution in tier three and be distributed in accordance with the process described in paragraphs (F)(3)(a) to (F)(3)(e) of this rule.

(3) A minimum of sixty per cent of the disproportionate share funds available to psychiatric hospitals as described in paragraph (H) of this rule will be distributed to the hospitals in tier three as described in paragraph(E)(3) of this rule according to the process described in paragraphs (F)(3)(a) to (F)(3)(e) of this rule.

(a) For each hospital in tier three, calculate the uncompensated care costs as described in paragraph (A)(8) of this rule.

(b) For all hospitals in tier three, sum all hospitals uncompensated care costs as described in paragraph (A)(8) of this rule.

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

(d) Multiply the ratio for each hospital calculated in paragraph (F)(3)(c) of this rule in tier three by the amount in paragraph (F)(3) of this rule to determine each hospital's disproportionate share payment amount.

(e) Each hospital will be distributed a payment amount based on the lesser of:

(i) Uncompensated care costs as determined in paragraph (A)(8) of this rule; or

(ii) The hospital's payment as determined in paragraph (F)(3)(d) of this rule.

(G) Payments.

The department shall make payment in accordance with paragraphs (E) and (F) of this rule, for hospitals that are eligible to participate in the medicaid program only for the provision of inpatient psychiatric services as described in rule 5101:3-2-01 of the Administrative Code that meet the criteria described in paragraph (D) of this rule.

(H) 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 5101:3-2-09 of the Administrative Code from the state's disproportionate share limit payment allotment determined by the United States center for medicare and medicaid services (CMS) for that program year.

Effective: 09/15/2006
R.C. 119.032 review dates: 06/14/2006 and 09/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5112.03
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5112.01 , 5112.03 , 5112.21
Prior Effective Dates: 8/12/95, 6/1/96 (Emer), 9/25/96 (Emer), 12/5/96, 12/6/97, 9/10/98, 9/26/99, 9/28/00, 9/27/01, 7/22/02, 7/28/03, 7/1/04, 7/22/05

5160-2-21 Policies for outpatient hospital services.

(A) All hospitals that are subject to DRG (diagnosis related group) prospective payment as described in rule 5160-2-07.1 of the Administrative Code and that provide covered outpatient hospital services to eligible medicaid beneficiaries as defined in rule 5160-2-02 of the Administrative Code are subject to the payment policies described in this rule.

(B) The words and terms described in paragraphs (B)(1) to (B)(4) of this rule have the following meanings, unless the context indicates otherwise.

(1) Outpatient invoice.

An "outpatient invoice" is a bill, submitted in accordance with Chapter 5160-1 of the Administrative Code, to the department for services rendered to one eligible medicaid beneficiary on one or more date(s) of service. An invoice encompassing more than one date of service is referred to in this rule as a "cycle bill."

(2) Outpatient claim.

An "outpatient claim" is defined as those outpatient services rendered to one eligible medicaid beneficiary on one date of service. In the instance of "cycle bills," as indicated in paragraph (B)(1) of this rule, more than one claim may appear on an invoice.

(3) Procedure code.

In this rule, a "procedure code" refers to the current procedural terminology (CPT) codes and healthcare common procedure coding system (HCPCS) as defined in rule 5160-1-19 of the Administrative Code. Guidelines and definitions for level of care determinations and for new and established patient definitions are as published in the CPT and HCPCS volumes. Applicable HCPCS modifiers are listed in appendix A to this rule.

CPT codes 92004 and 92014 for comprehensive vision exams are covered for eligible medicaid beneficiaries, and must be billed with HCPCS modifier -UB, as listed in appendix A to this rule, to indicate medicaid beneficiaries who are age twenty or younger or sixty or older. Comprehensive vision examinations are subject to the limitations defined in rule 5160-6-04 of the Administrative Code.

(4) Revenue center codes.

"Revenue center codes", as referenced in this rule, are as listed in appendix A to rule 5160-2-02 of the Administrative Code.

(5) National drug code

"National drug code" (NDC) is the actual coding used on the pharmaceutical container from which the product was dispensed and that satisfies the medicaid drug rebate requirements.

(C) Implementation and billing procedures.

The provisions of this rule are effective for claims associated with outpatient hospital services delivered on or after the effective date of this rule.

All outpatient services must be billed in accordance with Chapter 5160-1 of the Administrative Code. All revenue centers listed in appendix B to this rule require CPT or HCPCS coding. Additionally, a date of service is required on each line of the invoice for each service rendered. A diagnosis code(s) indicating the reasons for the outpatient treatment is required on each invoice. All physician, home health, and other professional services must continue to be billed separately.

(D) Dialysis service claims.

A dialysis service claim is identified by the presence of a CPT code in the range 90951 through 90999.

Dialysis services will be paid according to the fee schedule in appendix F to this rule. Radiology, pregnancy, and laboratory services will continue to be paid in accordance with paragraphs (I) and (K) of this rule. IV therapy will be paid in accordance with paragraph (G)(2)(e) of this rule and ancillary services will be paid in accordance with paragraph (J) of this rule.

(E) Chemotherapy service claims.

A chemotherapy service claim is identified by the presence of a CPT code in the range 96400 through 96549, excluding codes 96521, 96522, and 96523. Except for radiology services that will be paid in accordance with paragraph (I) of this rule, and laboratory and pregnancy services that will be paid in accordance with paragraph (K) of this rule, allowable charges submitted on chemotherapy service claims will be paid by multiplying those charges by the hospital's medicaid outpatient per cent. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

(F) Outpatient surgical service claims.

(1) Surgical service billing requirements.

An "outpatient surgical service claim" is a claim that does not include chemotherapy, or emergency room codes modified by modifier -22 (as described in paragraphs (E) and (H)(1) of this rule) and that carries a CPT code that is in the range 10021-69990 and that is also listed in appendix C to this rule as a grouped outpatient surgical code.

If a claim is submitted that carries a CPT code that is in the range 10021-69990 that is not a grouped outpatient surgical code because the procedure is primarily performed on an inpatient basis, the claim will be paid a per cent of charges, to be determined by the medicaid outpatient per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code. Claims for outpatient surgery services must include all outpatient services performed on that date of service.

(2) Surgical services claims payment.

(a) Unlisted surgical procedures.

A surgical procedure is defined as "unlisted" if the CPT code ends in "99" and is defined as an "unlisted procedure" in the description or is surgical CPT code number 23929, 26989, 37501, 38589, 43289, 43659, 44238, 44979, 47379, 47579, 49329, 49659, 50549, 50949, 55559, 58578, 58579, 58679, 59897, 59898, 60659, 69949, or 69979.

For dates of service between January 1, 2012 and December 31, 2013: When a surgical service claim carries an unlisted surgical procedure code, line item charges on the claim, except for those line items that carry radiology CPT codes (36251, 36252, 36253, 36254, 70010 to 79999), pregnancy codes, or laboratory CPT codes (36415, 36416, 80047 to 89399), will be paid by multiplying those charges by the hospital's medicaid outpatient per cent. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code. Radiology service line items will be paid in accordance with paragraph (I) of this rule; laboratory and pregnancy service line items will be paid in accordance with paragraph (K) of this rule; observation services will be paid in accordance with appendix F of this rule.

Unlisted surgical procedures, when used to bill a canceled surgery, must be billed with an attachment describing the surgical procedure(s) that were canceled. These unlisted canceled surgeries will be reviewed by the department and the reimbursement amount will be determined on a case-by-case basis.

For dates of service on or after January 1, 2014: Unlisted surgery codes will be assigned to a surgical group and paid according to the methodology in paragraphs (F)(2)(b) and (F)(2)(c) of this rule, except as provided in paragraph (F)(2)(b)(iii) of this rule.

(b) Surgical procedure codes that are not unlisted.

(i) When a claim carries a CPT surgery code and no unlisted surgical procedures, the claim will be assigned to a surgical grouping. If a hospital is a children's hospital as described in rule 5160-2-07.2 of the Administrative Code, surgeries will be reimbursed in accordance with the level 1 surgical group rates shown in appendix C to this rule. Payments for surgeries for all other hospitals subject to this rule, that are not children's hospitals, will be in accordance with the level 2 surgical group rate shown in appendix C to this rule. If the claim includes one surgical CPT code, payment will be based upon the surgical payment rate of the group listed in appendix C to this rule to which that CPT code is assigned.

If the claim includes two or more surgical procedure codes that are not identical, payment will be based on one hundred per cent of the surgical payment rate of the highest group listed in appendix C to this rule to which one of the surgical CPT procedure codes is assigned. Additional payment will be made by multiplying .50 times the surgical payment rate of the group(s) to which the other surgical CPT code(s) is(are) assigned.

If the claim includes identical surgical procedure codes, and the identical codes occur in conjunction with the same revenue center code, payment for the first surgery will be based on one hundred per cent of the surgical payment rate of the group to which that CPT code is assigned. Each additional occurrence of that identical surgical procedure code will be reimbursed by multiplying .50 times the group payment rate.

If the claim includes identical surgical CPT codes but those codes are not in conjunction with identical revenue center codes or if those CPT codes represent procedures that would not be performed more than one time on the same patient on the same day, no surgical group payments in addition to the one payment of one hundred per cent of the group rate will be made.

The payment rates shown in appendix C to this rule represent payment in full for all services performed in conjunction with outpatient surgery except for radiology, pregnancy, laboratory services and observation services. Radiology service line items will be paid in accordance with paragraph (I) of this rule; laboratory and pregnancy service line items will be paid in accordance with paragraph (K) of this rule, and observation services will be paid in accordance with appendix F to this rule.

(ii) Surgical claim edits.

Surgical CPT codes that include the administration of anesthesia in the description of that CPT code will only be reimbursed when an anesthesia CPT code in the range 00100-01999 is also coded on the claim. These surgical CPT codes that must be used in conjunction with an anesthesia code are identified in appendix C to this rule.

Certain surgical CPT codes will be reimbursed only when they appear on a claim that contains no other CPT codes in the surgery range. The CPT codes that must appear alone for reimbursement are those in the surgical range that are usually performed as part of another surgery. These codes are identified in appendix C to this rule. Certain surgical CPT codes will only be reimbursed if a prior authorization number is obtained from the department in accordance with rule 5160-2-03 of the Administrative Code. These codes are identified in appendix C to this rule.

(iii) Special unlisted dental surgery pricing for claims with an intellectual disability diagnosis code.

For hospitals that had a ratio of unlisted dental surgery services provided to patients with an intellectual disability diagnosis to total unlisted dental surgery services greater than the calendar year 2012 Ohio medicaid fee-for-service mean ratio of unlisted dental surgery claims with an intellecutal disability diagnosis to total unlisted dental surgery services plus three standard deviations and also had an average cost for unlisted dental surgery services provided to individuals with intellectual disabilities greater than the calendar year 2012 Ohio medicaid fee-for-service mean cost for unlisted dental surgery services provided to individuals with an intellecutal disability diagnosis: Claims billed with CPT code 41899 and an ICD-9 diagnosis code of 317, 318.0, 318.1, 318.2, or 319 will be paid $5,500 per claim, for dates of service between January 1, 2014 and December 31, 2015.

(c) Canceled surgeries.

It is the intent of the department to reimburse hospitals for canceled surgeries that are the result of medical complications arising after the patient is in the operating room.

To qualify for payment for a canceled surgery, the invoice must carry the occurrence code established to report the scheduled date of the canceled surgery and the CPT code for the surgery must be modified by the CPT modifier -73 or -74, as listed in appendix A to this rule, to report the canceled surgery.

If the code indicating that medical complications arose after patient prepping but before anesthesia is used, the payment will be based upon fifty per cent of the scheduled surgery group payment rate. If the code indicating that medical complications arose after anesthesia was induced is used, payment will be based upon one hundred per cent of the scheduled surgery group payment rate.

If a multiple surgery had been scheduled, the appropriate percentage (fifty or one hundred per cent) will be applied to the highest surgery payment group to which the scheduled surgery codes are assigned.

(G) Clinic service claims.

(1) Clinic service billing requirements.

A claim is identified as a "clinic claim" if it carries one of the clinic visit codes listed in appendix D to this rule and does not include dialysis, chemotherapy, or surgical services as described in paragraphs (D), (E), and (F) of this rule.

More than one clinic visit per beneficiary, per provider, per day is permissible and reimbursable if each clinic visit occurs in a distinct and separate clinic or if the patient visits the clinic, leaves the hospital, and subsequently returns on the same date of service. If the patient had a clinic visit on the same day as a visit to the emergency room of the same hospital, the emergency room visit may also qualify for payment as listed in appendix E to this rule.

(2) Clinic service claim payment.

Payments for clinic visits will be made in accordance with the fees listed in appendix D to this rule. If a hospital is a teaching hospital or a children's hospital as described in rule 5160-2-07.2 of the Administrative Code, clinic visits will be reimbursed in accordance with the level 1 clinic visit fee schedule shown in appendix D to this rule. Payments for clinic visits for all other hospitals subject to this rule will be in accordance with the level 2 clinic visit fee schedule shown in appendix D to this rule. Payments for clinic visits represent payment in full except for the additional payments that may be made for services described in paragraphs (G)(2)(a) to (G)(2)(f) of this rule.

(a) Additional payments may be made for ancillary services listed in appendix F to this rule.

(b) Additional payments may be made for laboratory services in accordance with paragraph (K) of this rule.

(c) Additional payments may be made for radiology services in accordance with paragraph (I) of this rule.

(d) Additional payments may be made for emergency room visits in accordance with appendix E to this rule.

(e) For dates of service between January 1, 2012 and December 31, 2013: Additional payments will be made for charges listed in line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) when the claim carries IV therapy CPT code 96365, 96366, 96367, or 96368. These additional payments will be calculated by multiplying those charges listed in those line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) by the hospital's medicaid outpatient per cent. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

For dates of service on or after January 1, 2014: Additional payments will be made for charges listed in line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) when the claim carries IV therapy CPT code 96365, 96366, 96367, or 96368. These additional payments will be calculated by multiplying those charges listed in those line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) by sixty per cent of the hospital's medicaid outpatient per cent. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

(f) Additional payments may be made for pregnancy services in accordance with paragraph (K) of this rule.

(H) Emergency room visit claims.

(1) Emergency room visit billing requirements.

(a) A claim is identified as an "emergency room visit claim" if it carries one of the emergency room visit codes listed in appendix E to this rule and does not include dialysis, chemotherapy, surgical, or clinic services as described in paragraphs (D), (E), (F), and (G) of this rule.

(b) More than one emergency room visit per beneficiary, per provider, per day is permissible and reimbursable if the patient visits the emergency room, leaves the hospital, and subsequently returns to the emergency room on the same date of service.

(c) If the service provided is greater than that usually required for the emergency room procedure because the procedure involved stabilizing a patient in a life-threatening condition prior to transferring the patient to another hospital or if the patient died in the emergency room following treatment or resuscitation efforts, the emergency room procedure code should be modified by the CPT modifier -22. This modifier is not to be used when the hospital does not provide active treatment for the patient (for example, when a patient does not require stabilization prior to transfer or when a patient dies prior to treatment or resuscitation efforts being made).

(2) Emergency room claim payment.

Payments for emergency room procedure codes with CPT modifier -22 will be made by multiplying claim charges, except for charges for radiology, pregnancy, and laboratory services, by the hospital's medicaid outpatient per cent. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code. Radiology services reported on those claims will be paid in accordance with paragraph (I) of this rule; laboratory and pregnancy service line items will be paid in accordance with paragraph (K) of this rule.

Payment for other emergency room visits will be made in accordance with the fee schedule listed in appendix E to this rule. If a hospital is a teaching hospital, as defined in rule 5160-2-07.2 of the Administrative Code, payments for emergency room visits will be made in accordance with the level 1 emergency room fee schedule listed in appendix E to this rule. If a hospital is a children's hospital, as described in rule 5160-2-07.2 of the Administrative Code, emergency room visits will be reimbursed in accordance with the level 2 emergency room visit fee schedule shown in appendix E to this rule.

Payments for emergency room visits for all other hospitals subject to this rule will be made in accordance with the level 3 emergency room visit fee schedule shown in appendix E to this rule. Payments for emergency room visits represent payment-in-full except for the additional payments which may be made for services described in paragraphs (H)(2)(a) to (H)(2)(e) of this rule.

(a) Additional payments may be made for ancillary services listed in appendix F to this rule.

(b) Additional payments may be made for laboratory services in accordance with paragraph (K) of this rule.

(c) Additional payments may be made for radiology services in accordance with paragraph (I) of this rule.

(d) For dates of service between January 1, 2012 and December 31, 2013: Additional payments will be made for charges listed in line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) when the claim carries IV therapy CPT code 96365, 96366, 96367, or 96368. These additional payments will be calculated by multiplying those charges listed in those line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) by the hospital's medicaid outpatient per cent. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

For dates of service on or after January 1, 2014: Additional payments will be made for charges listed in line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) when the claim carries IV therapy CPT code 96365, 96366, 96367, or 96368. These additional payments will be calculated by multiplying those charges listed in those line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 066 (with a valid HCPCS J code) by sixty per cent of the hospital's medicaid outpatient per cent. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

(e) Additional payments may be made for pregnancy services in accordance with paragraph (K) of this rule.

(I) Radiology services.

Payments for radiology services will be made in accordance with the fee schedule listed in appendix G to this rule. Reimbursement for outpatient hospital radiology services shall be the lower of charges or the payment amounts in the outpatient hospital radiology fee schedule as published in appendix G to this rule.

(J) Ancillary services.

As of October 1, 1994, designated free vaccines, as listed in rule 5160-4-12 of the Administrative Code, shall include all immunizations covered under the federal "Vaccines for Children" (VFC) program. All designated free vaccines and nondesignated vaccines shall be administered in accordance with the requirements described in rule 5160-4-12 of the Administrative Code.

Payments for ancillary services, including designated free vaccines and nondesignated vaccines, listed in appendix F to this rule will be made in accordance with appendix F to this rule if the listed codes appear on a claim that does not include chemotherapy, surgery services, or emergency room procedure codes with CPT modifier -22 as described in paragraphs (E), (F), and (H)(1) of this rule. Reimbursement for all immunizations covered under the VFC program will be five dollars for individuals eighteen years of age or younger. For dates of service on or after January 1, 2010, reimbursement for all immunizations covered under the VFC program will be increased to ten dollars for individuals eighteen years of age or younger.

Payments for ancillary services will be made in accordance with appendix F to this rule.

(1) Additional payments may be made for laboratory services in accordance with paragraph (K) of this rule.

(2) Additional payments may be made for radiology services in accordance with paragraph (I) of this rule.

(3) For dates of service between January 1, 2012 and December 31, 2013: Additional payments will be made for charges listed in line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) when the claim carries IV therapy CPT code 96365, 96366, 96367, or 96368. These additional payments will be calculated by multiplying those charges listed in those line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) by the hospital's medicaid outpatient per cent. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

For dates of service on or after January 1, 2014: Additional payments will be made for charges listed in line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) when the claim carries IV therapy CPT code 96365, 96366, 96367, or 96368. These additional payments will be calculated by multiplying those charges listed in those line items that carry revenue center code 025X (with no CPT code present) and/or revenue center code 0636 (with a valid HCPCS J code) by sixty per cent of the hospital's medicaid outpatient per cent. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

(4) Additional payments may be made for pregnancy services in accordance with paragraph (K) of this rule.

(K) Laboratory and pregnancy related services.

Payments for laboratory services will be made in accordance with the fee schedule listed in appendix H to this rule. Reimbursement for outpatient hospital laboratory services shall be the lower of charges or the payment amounts in the outpatient hospital laboratory fee schedule.

Payments for pregnancy related services will be made in accordance with the fee schedules listed in appendices D and F to this rule. When billing for pregnancy related services, bill the appropriate codes as identified in appendix D and/or F to this rule, with modifier -TH to indicate that obstetrical services, prenatal or post-partum, were provided.

(L) Independently billed services:

Claims submitted without dialysis, chemotherapy, surgical, clinic, emergency room, radiology, ancillary, laboratory, or pregnancy related services as defined in paragraphs (D) to (K) of this rule will be considered independently billed.

(1) Pharmacy.

For dates of service January 1, 2012 and December 31, 2013: Claims submitted with line items that carry revenue center codes 025X (with no CPT code present) and/or 0636 (with a valid HCPCS J code) will be paid at the hospital's medicaid outpatient per cent of charges The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

For dates of service on or after January 1, 2014: Claims submitted with line items that carry revenue center codes 025X (with no CPT code present) and/or 0636 (with a valid HCPCS J code) will be paid at sixty per cent of the hospital's medicaid outpatient per cent of charges. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

(2) Medical supply.

For dates of service between January 1, 2012 and December 31, 2013: Claims submitted with line items that carry revenue center codes 027X (with no CPT code present) will be paid at the hospital's medicaid outpatient per cent of charges. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

For dates of service on or after January 1, 2014: Claims submitted with line items that carry revenue center codes 027X (with no CPT code present) will be paid at sixty per cent of the hospital's medicaid outpatient per cent of charges. The medicaid outpatient per cent is the per cent described in paragraph (B)(2) of rule 5160-2-22 of the Administrative Code.

(M) Observation services

Payments for observation services will be made in accordance with appendix F to this rule. Payments for observation services will be made for up to two consecutive days only. To receive payment for a third consecutive date of service, the patient must have been discharged, and, for medically necessary reasons, readmitted as an outpatient.

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Effective: 03/31/2014
R.C. 119.032 review dates: 12/01/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02 , 5164.70
Prior Effective Dates: 04/01/1988 (Emer), 04/23/1988, 06/30/1989 (Emer), 08/10/1989, 06/29/1990 (Emer), 08/11/1990, 09/03/1991 (Emer), 11/10/1991, 07/01/1992, 10/01/1992 (Emer), 11/17/1992 (Emer), 12/31/1992, 07/01/1993, 07/01/1994, 09/30/1994 (Emer), 12/30/1994, 12/29/1995 (Emer), 03/16/1996, 12/31/1996 (Emer), 03/22/1997, 12/31/1997 (Emer), 03/19/1998, 07/02/1998, 12/31/1998 (Emer), 03/31/1999, 01/04/2000 (Emer), 03/20/2000, 12/29/2000 (Emer), 03/30/2001, 12/31/2001 (Emer), 03/25/2002, 07/01/2003, 09/01/2003 (Emer), 11/27/2003, 01/02/2004 (Emer), 04/01/2004, 01/01/2005, 12/30/2005 (Emer), 03/27/2006, 12/29/2006 (Emer), 03/29/2007, 12/31/2007 (Emer), 03/30/2008, 12/31/2008 (Emer), 03/31/2009, 10/01/2009 (Emer), 12/3/2009, 12/31/2009 (Emer), 03/31/2010, 12/30/2010 (Emer), 03/30/2011, 12/22/2011, 12/30/2011 (Emer), 03/29/12, 12/31/2012 (Emer), 03/28/2013, 12/18/2013 (Emer)

5160-2-21.1 Consumer co-payments for non-emergency emergency department services.

(A) This rule establishes a consumer co-payment for non-emergency emergency department services as authorized by section 5111.0112 of the Revised Code. The provisions in this rule do not apply to consumers enrolled in the medicaid managed health care program.

(B) Definitions.

(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 January 1, 2006, medicaid consumers shall 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. Hospital providers shall report, through claim submission, the applicable co-payment to the department in accordance with hospital billing instructions.

(D) Exclusions and additional limitations to the co-payment requirement for non-emergency care provided in an emergency department are in accordance with rule 5101:3-1-09 of the Administrative Code, except as provided in paragraph (E) of this rule.

(E) A hospital may take action to collect a co-payment by providing, at the time services are rendered to a medicaid recipient, notice that a co-payment may be owed. If the hospital provides the notice and chooses not to take further action to pursue collection of the co-payment, the prohibition against waiving co-payments, as described in paragraph (B)(3) of rule 5101:3-1-09 of the Administrative Code, does not apply.

(F) Reimbursement for services subject to the co-payment for non-emergency emergency department services. The department shall reimburse the emergency department claim the allowable medicaid payment, in accordance with rule 5101:3-2-21 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 5101:3-2-25 of the Administrative Code.

Effective: 09/15/2006
R.C. 119.032 review dates: 06/27/2006 and 09/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.0112 , 5111.02
Rule Amplifies: 5111.01 , 5111.0112 , 5111.02 , 5111.021
Prior Effective Dates: 1/1/2006

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

This rule applies to all hospital services excluded from inpatient hospital, diagnosis related prospective payment.

(A) Applicability.

(1) Reasonable cost reimbursement, for services provided on or before September 30, 2014, where interim payments are made to approximate cost based on a historical cost-to-charge ratio, and where reasonable costs actually incurred during a period are subsequently reconciled to interim payments, applies to:

(a) All outpatient hospital services provided by non-Ohio hospitals excluded from inpatient prospective payment as set forth in rule 5160-2- 07.1 of the Administrative Code which file the JFS 02930 cost report.

(b) All outpatient hospital services provided by Ohio hospitals excluded from inpatient prospective payment as set forth in rule 5160-2- 07.1 of the Administrative Code.

(c) Inpatient services provided by hospitals excluded from prospective payment as set forth in rule 5160-2- 07.1 of the Administrative Code.

(d) Inpatient capital-related costs as set forth in rule 5160-2- 07.6 of the Administrative Code.

(2) Cost-related reimbursement, where interim payments are made to approximate cost based on a historical cost-to-charge ratio but where no subsequent reconciliation occurs, applies to:

(a) Outpatient hospital services provided by non-Ohio hospitals excluded from inpatient prospective payment as set forth in rule 5160-2- 07.1 of the Administrative Code which do not file the JFS 02930 cost-report.

(b) Certain outpatient hospital services as as described in rule 5160-2-21 of the Administrative Code.

(3) Services described in paragraph (A) (1) of this rule and provided on or after October 1, 2014 shall not be subsequently reconciled.

(B) Payments under non-DRG prospective payment.

(1) For hospital services provided on or before September 30, 2014, providers will receive an interim payment as described in paragraph (B)(2) of this rule. These interim payments will be reconciled to the lower of reasonable cost incurred on behalf of medicaid recipients during the time period or total allowed charges for medicaid recipients during the time period.

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

(b) For those hospitals which do not file the JFS 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 JFS 02930, schedule H, section II for all Ohio hospitals, divided by the sum of medicaid outpatient charges as reported on JFS 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 JFS 02930, schedule H, section I for all Ohio hospitals, divided by the sum of medicaid inpatient charges as reported on the JFS 02930, schedule H, section I for all Ohio hospitals.

(c) The ratio used for an interim 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.

(3) For services provided on or after October 1, 2014 by hospitals subject to non-DRG prospective payment, the historical cost-to-charge ratio described in paragraph (B)(2) of this rule shall be either:

(a) Ninety per cent of the calculated cost-to-charge ratio for freestanding rehabiliation hospitals and freestanding long-term care hospitals, as defined in rule 5160-2- 07.2 of the Administrative Code;

(b) Or for cancer hospitals, as defined in rule 5160-2- 07.2 of the Administrative Code, the reimbursement rate shall be:

(i) Ninety-seven per cent of the calculated cost-to-charge ratio for discharges on or after October 1, 2014 and on or before June 30, 2015;

(ii) Ninety-four per cent of the calculated cost-to-charge ratio for discharges on or after July 1, 2015 and on or before June 30, 2016;

(iii) Ninety-one and seven tenths per cent of the calculated cost-to-charge ratio for discharges on or after July 1, 2016.

(C) In general, reasonable cost reimbursement recognizes costs that are reasonable and allowable under Title XVIII standards and principles described in 42 CFR 413.1 through 413.40 effective as of October 1, 2013, 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 reasonable cost 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- 19.3 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 5160-2-25 of the Administrative Code.

(f) Costs which exceed limits described in 42 CFR 413.30 effective as of October 1, 2013 except that the department may exempt certain facilities from these limits as described in 42 CFR 413.30 . The determinations to exempt facilities according to 42 CFR 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 CFR 412.1 through 412.125 effective as of October 1, 2013 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.

Effective: 08/21/2014
R.C. 119.032 review dates: 06/04/2014 and 08/21/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 6-3-83, 10-1-83 (Emer.), 12-29-83 (Emer.), 2-1-84, 10-1-84, 7-29-85, 7-3-86, 10-19-87, 4-23-88, 7-1-88 (Emer.), 9-29-88, 7-1-89, 9-3-91 (Emer.), 11-10-91, 7-1-92; 5-1-00, 1-1-05

5160-2-23 Cost reports.

(A) For cost-reporting purposes, the medicaid program requires each eligible provider, as defined in rule 5101:3-2-01 of the Administrative Code, 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 only delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (H) of this rule.

Effective for medicaid cost reports filed for cost-reporting periods ending in state fiscal year (SFY) 2003, and each cost-reporting period thereafter, any hospital that fails to submit cost reports on or before the dates specified by ODJFS shall be fined one thousand dollars for each day after the due date that the information is not reported.

The hospital shall complete and submit the JFS 02930 "Hospital Cost Report" in accordance with instructions contained in this rule. The JFS 02930 (rev. 4/ 2011) for SFY 2011 and its instructions are shown in the appendix to this rule. The hospital's cost report must:

(1) Be prepared in accordance with medicare principles governing reasonable cost reimbursement set forth in the providers' reimbursement manual "CMS Publications 15, 15-1 and 15-2," available at http://www.cms.hhs.gov/Manuals/PBM/list.asp#TopOfPage dated September 8, 2005.

(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 instructions in the appendix to this rule an electronic copy of the medicare cost report, which must 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 OBRA survey. In addition, all subsequent revisions to the cost report must include an executed certification.

(5) Effective for medicaid cost reports filed for cost-reporting periods ending in SFY 2003, and each cost-reporting period thereafter, the executed certification shall require the officer of the hospital to acknowledge that an independent party, a 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" shall also 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 due by December thirty-first of the same calendar year. For hospital reporting periods ending between July first and December thirty-first, the cost report is due by June thirtieth of the following calendar year. Extensions may be granted as specified in the appendix to this rule.

(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 October 1, 2006, 42 C.F.R. 412.27 effective July 1, 2006, and 42 C.F.R. 412.29 effective January 1, 2005, must identify distinct part unit costs separately within the cost report as described in paragraph (A) of this rule.

(C) Ohio hospitals performing transplant services covered under medicaid as described in rule 5101:3-2-07.1 of the Administrative Code must identify transplant costs, charges, days, and discharges separately within the cost report as described in paragraph (A) of this rule.

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

(E) Ohio hospitals providing services to medicaid managed care plan (MCP) enrollees must identify MCP costs, charges and payments separately within the cost report as described in paragraph (A) of this rule.

(F) 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 the ODJFS prior to any applicable final adjustment and settlement. If an amount is due ODJFS as a result of the filing, payment must be forwarded, in accordance with the instructions in the appendix to this rule, at the time the cost report is submitted for it to be considered a complete filing. Any revised interim cost report must be received within thirty days of the provider's receipt of the interim cost settlement. A desk audit will be performed by the hospital audit section on all as filed and interim cost reports. An interim cost settlement by ODJFS 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 must 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 (F) of this rule.

(2) Adjustments may be made to the interim cost report as described in rule 5101:3-2-24 of the Administrative Code.

(G) Out-of-state providers that are not paid on a prospective payment basis and provide inpatient and/or outpatient services to eligible Ohio Title XIX recipients will be required to file the cost report identified in this rule.

(H) Hospitals that fail to submit cost reports timely as defined in paragraph (A) of this rule will receive a delinquency letter from the ODJFS 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. Claims affected by suspension of payment are not considered to be clean claims as "clean claims" are defined in rule 5101:3-1-19.3 of the Administrative Code. 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 recommended in accordance with Chapter 5101:3-1 of the Administrative Code.

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Effective: 11/14/2011
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/30/77, 3/21/81, 11/11/82, 1/1/84, 10/1/84, 7/29/85, 10/1/85 (Emer), 12/22/85, 10/19/87, 4/23/88, 8/1/88 (Emer), 10/21/88, 2/22/89 (Emer), 5/8/89, 11/5/89, 5/25/90, 5/1/91, 5/1/92, 10/1/93 (Emer), 11/15/93, 1/20/95, 3/16/96, 7/1/96, 7/1/97, 4/26/99, 7/15/99, 10/18/99, 5/1/00, 5/17/01, 3/27/03, 7/17/03, 9/2/04, 9/17/05, 11/9/06, 9/17/07, 7/17/08, 2/26/10, 10/1/10

5160-2-24 Audits.

(A) General provisions.

(1) Audits will be conducted by the Ohio department of job and family services (herein referred to as the department) for services rendered by the hospital under the medicaid program. The examination of hospital costs and charges will be made in accordance with generally accepted auditing standards necessary to fulfill the scope of the audit. To facilitate this examination, providers are required to make available all records necessary to fully disclose the extent of services provided to program recipients, the corresponding costs and charges made and payments received for such services, and the provider's audited financial statement 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 requirements. Based on the audit, adjustments in payments to the provider will be made as required by provisions of this rule. Records necessary to fully disclose the extent of services provided must 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 must 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 5101:3-2-08, 5101:3-2-08.1, 5101:3-2-09 and 5101:3-2-10 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 reasonable cost basis.

(1) For hospital services reimbursed on a reasonable cost basis as identified in rule 5101:3-2-22 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 5101:3-2 of the Administrative Code;

(d) Costs reported to the department represent actual incurred, reasonable, and allowable costs in accordance with the provisions of rule 5101:3-2-22 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 C.F.R. 447.272 effective October 1, 2004 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 October 1, 2004;

(g) Amounts of third-party payments reported to the department as described in rules 5101:3-1-08 and 5101:3-2-25 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 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 5101:3-2-09 and 5101:3-2-10 of the Administrative Code were based upon data described in rules 5101:3-2-09 and 5101:3-2-10 of the Administrative Code.

(2) Underpayments or overpayments determined as a result of findings made under the provisions of paragraphs (B)(1) 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 5101:3-2-23 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 5101:3-2-09 and 5101:3-2-10 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 rule 5101:3-2-07.4 of the Administrative Code. For hospital services identified in rule 5101:3-2-07.1 of the Administrative Code as being 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 5101:3-2 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 C.F.R. 447.272 effective October 1, 2004 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 October 1, 2004.

(e) Amounts of third-party payments reported to the department as described in rules 5101:3-1-08 and 5101:3-2-25 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 5101:3-2-22 of the Administrative Code.

(g) Medicaid discharges 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 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 require analysis and auditor judgment to determine the appropriate type of adjustment.

(h) Amounts related to indigent care adjustments described in rules 5101:3-2-09 and 5101:3-2-10 of the Administrative Code were based upon data described in rules 5101:3-2-09 and 5101:3-2-10 of the Administrative Code.

(2) For hospitals subject to prospective payment for inpatient 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 and/or a discrepancy exists between reported medicaid charges and those reflected in the ODHS paid claims data file, the interim cost report may be adjusted to reflect inpatient days, 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) Federal audit findings submitted to the department after September 1, 1987 will be implemented as described in rule 5101:3-2-07.8 of the Administrative Code if the affected rate has been in effect for less than two prospective rate periods following implementation of rebased rate components and if the department notifies the affected hospital of the audit finding within thirty days of receipt of the finding. Hospitals may request reconsideration of the adjustment within thirty days of notification following the procedures outlined in rule 5101:3-2-07.12 of the Administrative Code.

(4) 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 paragraphs (C)(2) and (C)(3) 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 at settlements based upon findings associated with the cost-reporting period being settled. Retrospective adjustments to payment rates as described in rule 5101:3-2-07.8 of the Administrative Code that are identified prior to interim settlement will be incorporated into interim settlement in instances when such adjustments to payment rates affect payments for discharges occurring during 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 and all applicable retrospective adjustments to payment rates in effect for discharges occurring during the cost-reporting period 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 5101:3-2-07.12 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, and only 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.

Effective: 09/04/2005
R.C. 119.032 review dates: 05/27/2005 and 09/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 4/7/77, 10/1/84, 7/3/86, 10/19/87, 4/23/88, 8/1/88 (Emer), 10/13/88, 9/3/91 (Emer), 11/10/91, 7/1/92, 5/1/00

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

Rule 5101:3-1-08 of the Administrative Code sets forth general provisions regarding requirements that the department make payment for covered services only after any available third-party benefits are exhausted. In addition to those general provisions, this rule identifies other requirements applicable to services provided by hospitals.

(A) All hospitals are to utilize third-party resources for all services a consumer receives while in the hospital. If a hospital receives reimbursement from a third-party subsequent to submitting a claim or subsequent to 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 under spend-down provisions (see Chapter 5101:1-39 of the Administrative Code) are considered a third-party resource. Benefits available through Title XVIII of the Social Security Act under medicare, part A and part B, or through medicare part C (medicare advantage), are considered third-party resources, including medicare part A lifetime reserve days.

(B) The following payment provisions apply when billing for services provided to medicaid eligibles having 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 5101-3-2-07.11. of the Administrative Code in the case that a hospital is paid in accordance with the diagnosis related grouping (DRG) prospective payment system; or

(ii) Described in rule 5101-3-2-22 of the Administrative Code in the case that a hospital is paid on a reasonable cost basis.

(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 qualified medicare beneficiaries (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 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 5101-3-2-07.11 or 5101:3-2-21 of the Administrative Code in the case that a hospital is paid in accordance with the diagnosis related grouping(DRG) prospective payment system; or

(ii) Described in rule 5101-3-2-22 of the Administrative Code in the case that a hospital is paid on a reasonable cost basis.

(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 qualified medicare beneficiaries and medicaid consumers enrolled in medicare part C managed health care plans (medicare advantage plans) the department pays in accordance with rule 5101:3-1-05.1 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 DRG prospective payment as described in rule 5101-3-2-07.11 of the Administrative Code or the payment applicable for services reimbursed on a reasonable cost basis as described in rule 5101:3-2-22 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 and patient liabilities associated with persons eligible on a spend-down basis as described in paragraph (A) of this rule. For outpatient hospital services, if a consumer is entitled to hospital insurance benefits other than medicare, the department pays either in accordance with rule 5101:3-2-21 of the Administrative Code for hospitals subject to DRG prospective payment or in accordance with rule 5101:3-2-22 of the Administrative Code for hospitals subject to reimbursement on a reasonable cost basis, minus any resources available to the patient. Such resources may include patient liabilities associated with persons eligible on a spend-down basis as described in paragraph (A) of this rule. 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.

Effective: 01/01/2012
R.C. 119.032 review dates: 10/14/2011 and 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 10/1/84, 7/29/85, 9/3/91 (Emer), 8/1/02, 10/1/05

5160-2-30 Hospital franchise fee program.

This rule sets forth the hospital franchise fee assessment and payment schedule applicable for the assessment program year that ends in calendar year 2014, 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

The amount of each hospital's franchise fee assessment for the assessment program year that ends in calendar year 2014 shall be 2.579425 per cent of the hospital's total facility costs as defined in paragraph (A) of this rule.

(C) Payment schedule

Except as provided in paragraph (D)(3) of this rule, each hospital shall pay the amount it is assessed under paragraph (B) of this rule according to the following payment schedule:

(1) Twenty-five per cent due on March 17, 2014.

(2) Twenty-five per cent due on April 7, 2014.

(3) Fifty per cent due on May 5, 2014.

(D) 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.

Effective: 02/24/2014
R.C. 119.032 review dates: 01/01/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02 , 5168.23 , 5168.26
Rule Amplifies: 5168.20 , 5168.21 , 5168.22 , 5168.23 , 5168.24 , 5168.25 , 5168.26 , 5168.27 , 5168.28
Prior Effective Dates: 10/14/10 (Emer), 1/1/11, 9/29/11 (Emer), 12/28/11, 3/10/13 (Emer), 7/29/13

5160-2-40 Pre-certification review.

This rule describes the pre-certification review program for inpatient and outpatient services. For the medical/surgical pre-certification program, paragraphs (A) to (C) and (E) to (G) of this rule are to be used. For the psychiatric pre-certification program, paragraphs (A)(12), (B) and (D) to (G) of this rule are to be used.

(A) Definitions.

(1) An "emergency admission" is an admission to treat a condition requiring medical and/or surgical treatment within the next forty-eight hours when, in the absence of such treatment, it can reasonably be expected that the patient may suffer unbearable pain, physical impairment, serious bodily injury or death.

(2) "Medically necessary services" are defined in paragraph (B) of rule 5101:3-2-02 of the Administrative Code.

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

(4) An "elective admission" is any admission that does not meet the emergency admission definition in paragraph (A)(1) of this rule.

(5) "Elective care" is medical or surgical treatment that may be postponed for at least forty-eight hours without causing the patient unbearable pain, physical impairment, serious bodily injury or death.

(6) For purposes of this rule, a "hospital" is a provider eligible under rule 5101:3-2-01 of the Administrative Code.

(7) A "surgical admission" is an admission to a hospital in which surgery is performed as part of the treatment plan.

(8) A "medical admission" is a nonsurgical, nonpsychiatric, and nonmaternity admission.

(9) "Pre-certification" is a process whereby ODJFS (or its contractual designee) assures that covered medical and psychiatric services, and covered surgical procedures are medically necessary and are provided in the most appropriate and cost effective setting. Since it may be determined that an inpatient stay is not required for the provision of that covered medical or covered surgical care, the location of service delivery may be altered as a result of pre-certification. The payment of that treatment or procedure is contingent upon the acceptance of the review agency's recommendation on the appropriate location of service, and medical necessity of the admission and/or procedure. The department will mail the precertification list and standards of medical practice to all providers thirty days in advance of requiring pre-certification.

(B) Guidelines for pre-certification

(1) The decision that the provision of elective diagnostic and/or therapeutic 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 must be present to justify proposed care. When indicated, determinations will also include a consideration of relevant and appropriate psycho-social factors.

(2) The individual circumstances of each patient is taken into account 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 must be fully documented in the medical record in order to be considered as part of the review.

(C) Pre-certification of medical and surgical services provided in an inpatient or outpatient setting.

(1) Admission for individuals who are medicaid eligible at the time of the admission and who do not meet any of the exemptions in paragraph (C)(2) of this rule must be certified by the reviewing agency (ODJFS or its contractual designee) prior to an admission to a hospital as defined in paragraph (A)(6) of this rule.

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

(a) Emergency admissions, with the exception of emergency psychiatric admissions.

(b) Substance abuse admissions.

(c) Maternity admissions.

(d) Recipients enrolled in health insuring corporations under contract with the department for provision of health services to recipients.

(e) Services provided in hospitals which are located in noncontiguous states.

(f) Elective care that is performed in a hospital inpatient setting on a patient who is already hospitalized for a medically necessary condition unrelated to the elective care or when an unrelated procedure which does not require pre-certification is being performed simultaneously.

(g) Persons whose eligibility is pending at the time of admission or who make application for medicaid subsequent to admission.

(h) Patients who are jointly eligible for medicare and medicaid and who are being admitted under the medicare "part A" benefit.

(i) Patients who are eligible for benefits through a third party insurance as the primary payer for the services subject to pre-certification.

(j) Transfers from one hospital to another hospital with the exception of those hospitals identified for intensified review in accordance with paragraph (C)(1) of rule 5101:3-2-07.13 of the Administrative Code.

(k) Admissions for those elective surgical procedures or diagnoses which are not included in the department's pre-certification list.

(l) If the patient is not identified as a medicaid recipient at the time of an elective admission or procedure. However, every effort should be made by both the attending and/or admitting physicians and hospital providers to identify medicaid recipients before an admission or procedure that requires precertification.

(3) The provider must request pre-certification for an admission and/or procedure that does not meet the exemption criteria listed in paragraphs (C)(2)(a) to (C)(2)(l) of this rule and is on the department's pre-certification list by contacting the reviewing agency. The reviewing agency is to make a decision on a pre-certification request within three working days of receipt of a properly submitted request, which is to include the information addressed in the standards of medical practice. "Receipt of a properly submitted request" means that all information needed by the reviewing agency to make a decision based upon the guidelines in paragraph (B) of this rule has been provided to the reviewing agency. All negative decisions shall be reviewed by a physician representing ODJFS or its contractual designee. The reviewing agency shall notify in writing the recipient, the requesting physician, the hospital, and ODJFS of all decisions. The reviewing agency must provide that written notice is sent to the requesting physician, recipient, and hospital by the close of the fourth working day after the request is received.

(D) Pre-certification psychiatric.

(1) General information.

The following definitions pertain to psychiatric admissions:

(a) 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/surgical unit and an admission to a distinct part psychiatric unit within the same facility is considered to be a psychiatric admission and is subject to pre-certification.

(b) An "emergency psychiatric admission" is an admission where the attending psychiatrist believes that there is likelihood of serious harm to the patient or others and that the patient requires both intervention and a protective environment immediately.

(2) All psychiatric admissions for individuals who are medicaid eligible at the time of the admission must be certified by the reviewing agency (ODJFS or its contractual designee) prior to an admission to a hospital or by the next working day after the admission has occurred.

(3) The provider must request pre-certification for a psychiatric admission by contacting the reviewing agency. The reviewing agency is to make a decision on a pre-certification request within three working days of receipt of a properly submitted request, which is to include the information addressed in the standards of medical practice. "Receipt of a properly submitted request" means that 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 shall be reviewed by a physician representing ODJFS or its contractual designee. The reviewing agency shall notify the recipient, the requesting physician, the hospital, and ODJFS of all decisions in writing by the close of the fourth working day after the request is received.

(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 5101:3-2-07.12 of the Administrative Code.

(F) Recipients have a right to a hearing in accordance with division-level 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 for elective care subject to pre-certification review.

(1) A certification that an inpatient stay is necessary for the provision of care and/or a procedure is medically necessary does not guarantee payment for that service. The individual must be a medicaid recipient at the time the service is rendered and the service must be a covered service.

(2) An elective admission, as defined in paragraph (A)(4) of this rule, is reimbursed according to the rates for inpatient hospital services pursuant to rule 5101:3-2-22 of the Administrative Code for hospital admissions reimbursed on a cost basis and rule 5101:3-2-07.11 of the Administrative Code for hospital admissions reimbursed on a prospective basis. Outpatient hospital services are reimbursed according to rule 5101:3-2-21 of the Administrative Code for hospitals subject to prospective reimbursement, and according to rule 5101:3-2-22 of the Administrative Code for those hospitals reimbursed on a cost basis. Associated physician services are reimbursed according to medicaid maximums for physician services pursuant to appendix DD to rule 5101:3-1-60 of the Administrative Code.

(3) In any instance when an admission or a procedure that requires pre-certification is performed and the admission and/or procedure has not been approved, hospital payments will not be made. If physician payments have been made for services associated with the medically unnecessary procedure, such payments will be recovered by the department. Recipients may not be billed for charges associated with the admission and/or procedure except under circumstances described in paragraph (G)(4) of this rule.

(4) If the pre-certification process is initiated prospectively by the provider and hospital inpatient services are denied, or if an admission and/or procedure requiring pre-certification is not found to be medically necessary and the recipient chooses hospitalization or to have the medically unnecessary service, these admissions and/or procedures and all associated services would be considered noncovered services and the recipient will be liable for payment of these services in accordance with rule 5101:3-1-13.1 of the Administrative Code.

(5) The medical review entity may determine upon retrospective review, in accordance with rule 5101:3-2-07.13 of the Administrative Code, that the location of service was not medically necessary, but that services rendered were medically necessary. In this instance, 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 5101:3-2-21 of the Administrative Code. Only laboratory and diagnostic radiology services rendered during the remainder of the medically unnecessary admission may be billed in accordance with rule 5101:3-2-02 of the Administrative Code on the outpatient claim. The outpatient bill must be submitted with a copy of the reconsideration affirming the original decision and/or the administrative decision issued in accordance with rule 5101:3-2-07.12 of the Administrative Code. The outpatient bill with attachments must be submitted to the department within sixty days from the date on the remittance advice recouping the DRG payment for the medically unnecessary admission.

Eff 3-20-84; 10-1-84; 10-1-87; 4-1-88; 7-1-90; 9-3-91 (Emer.); 11-10-91; 7-1-92; 7-1-93; 1-1-00; Replaces: 5101:3-2-42 Eff 4-1-05
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
R.C. 119.032 review dates: 12/30/2004 and 04/01/2010

5160-2-50 Supplemental inpatient hospital upper limit payments for public hospitals.

(A) "Public hospital" means an Ohio hospital owned and operated by a governmental entity other than the state.

(B) For each public hospital, calculate the estimated amount that medicare would have paid for an inpatient hospital discharge if medicare were paying the care for medicaid consumers.

(1) Divide the total medicare inpatient hospital payment by the hospital's medicare inpatient hospital charges to calculate the hospital-specific medicare payment-to-charge ratio.

(2) Multiply the hospital-specific medicare payment-to-charge ratio by medicaid charges to calculate the estimated medicare payment for medicaid consumers.

(3) For each public hospital, calculate the available payment gap by taking total estimated medicare payment for medicaid discharges as calculated in paragraph (A)(2) of this rule and subtracting actual medicaid payments.

(4) For each public hospital that has an available inpatient payment gap greater than zero resulting from the calculations in paragraph (B)(3) of this rule, calculate the available per-discharge supplemental inpatient hospital payment amount by dividing the amount in paragraph (B)(3) of this rule by the public hospital's medicaid discharges.

(C) The amount calculated in paragraph (B) of this rule will be in effect from July 1, 2011 to June 30, 2013.

(D) The source data for calculations described in this rule will be based on cost reporting data described in rule 5101:3-2-23 of the Administrative Code, which reflects the hospital fiscal year ending state fiscal year 2010, and the medicare cost report (CMS 2552-96) for the corresponding cost reporting period.

(E) Payments will be made on a semi-annual basis, based upon actual medicaid discharges paid during the prior six-month period, subject to the provisions of paragraph (B) of this rule.

(F) Supplemental payments to cost-based providers, as specified in rule 5101:3-2-07.1 of the Administrative Code, will be excluded from the cost settlement process.

(G) Hospital payments made under this section, when combined with other payments made in accordance with this rule, shall not exceed the limit specified in 42 CFR 447.241.

(H) The total funds that will be paid to each public hospital as described in paragraph (E) of this rule will be included in the calculation of disproportionate share limits as described in rule 5101:3-2-07.5 of the Administrative Code.

Replaces: 5101:3-2-50

Effective: 08/24/2012
R.C. 119.032 review dates: 08/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , Section 309.30.33 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 11/15/01, 7/1/04, 4/1/09, 4/8/10

5160-2-51 Supplemental inpatient hospital upper payment limit payments for state hospitals.

(A) "State hospital" means an Ohio hospital owned and operated by the state.

(B) Non-psychiatric state hospitals, as of October first of the year preceding payments, shall be paid supplemental amounts for the provision of hospital inpatient services set forth in paragraphs (C) through (F) of this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

(C) Data sources used in calculating supplemental payments to state-owned hospitals include the medicare cost report (CMS 2552-96), the Ohio medicaid hospital cost report (JFS 02930, rev. 4/2010), and medicaid management information system (MMIS) inpatient fee-for-service date of service claims data. For state fiscal year (SFY) 2012 and 2013, the hospital fiscal year ending in state fiscal year 2010 medicare cost reports retrieved from the hospital cost report information system and the medicaid MMIS data and Ohio medicaid cost reports (JFS 02930, rev. 4/2010) payment data from the state fiscal year prior to the month of payment will be utilized unless otherwise noted.

(D) The total supplemental payments shall not exceed the amount calculated using the following methodology:

(1) For each non-psychiatric state hospital, total medicare costs are divided by total medicare charges to establish the cost-to-charge ratio.

(2) Ohio medicaid payments for the portion of the hospital fiscal year preceding October 1, 2009 are inflated by five per cent to account for an increase in medicaid payment rates effective October 1, 2009.

(3) Ohio medicaid charges are multiplied by the cost-to-charge- ratio in paragraph (D)(1) of this rule to establish estimated Ohio medicaid costs.

(4) Ohio medicaid costs from paragraph (D)(3) of this rule are inflated using a hospital-specific five year average of medicaid costs per patient day. This hospital-specific inflation factor is applied to individual hospital costs at a discounted rate for the partial year for all hospitals with fiscal year end before the 2010 state fiscal year end of June 30, 2010, plus two years to determine the upper payment limit (UPL) for SFY 2012 and for a third year to determine the UPL for SFY 2013. In the event in which hospital data does not exist for any hospital in years 2005-2009, the state average of 4.43 per cent is utilized. Ohio medicaid costs are multiplied by a factor of 1.01 for the critical access hospitals.

(5) Ohio medicaid payments from paragraph (D)(2) of this rule are then subtracted from the total in paragraph (D)(4) of this rule to find the inpatient UPL gap for state hospitals. The sum of the differences for these state hospitals represents the total state-owned inpatient upper payment limit gap.

(E) Each non-psychiatric state hospital paid under the prospective payment system shall receive payments based on the following hospital-specific calculation:

(1) For each non-psychatric state hospital, calculate a medicare payment-to-charge ratio by dividing total medicare inpatient payments by total medicare inpatient charges.

(2) For each non-psychiatric state hospital, calculate the total estimated medicare inpatient payment for medicaid inpatient discharges by multiplying the amount calculated in paragraph (E)(1) of this rule by the total medicaid inpatient charges.

(3) For each non-psychiatric state hospital, subtract total inpatient medicaid payments from the amount calculated in paragraph (E)(2) of this rule.

(4) The pooled amount will then be equal to the summation of the amounts calculated for all non-psychiatric state hospitals in accordance with paragraph (E)(3) of this rule.

(5) Each non-psychiatric state hospital for which the amount calculated in paragraph (E)(3) of this rule is greater than zero shall receive an allotment of the pooled amount calculated in paragraph (E)(4)) of this rule. This allotment is based on the ratio of hospital-specific medicaid discharges to the total state hospital medicaid discharges.

(F) From a pool of funds calculated in paragraph (D)(5) of this rule, less the payments made in paragraph (E)(5)) of this rule, resulting in a remaining pool amount, state hospitals shall receive a percentage increase in inpatient medicaid payments. The percentage increase on state fiscal year 2010 total inpatient hospital medicaid payments will be equal to the remaining pool amount divided by state hospital medicaid inpatient hospital fee-for-service payments.

(G) Using the source data described in paragraph (C) of this rule), for each freestanding psychiatric state hospital owned or operated by the state, calculate the estimated amount that medicare would have paid for an inpatient discharge if medicare were paying the care for medicaid consumers by subtracting medicaid inpatient payments from medicaid inpatient costs.

(H) For each state psychiatric hospital that has an inpatient payment gap greater than zero resulting from the calculations in paragraph (G) of this rule, calculate the per discharge supplemental inpatient hospital payment amount by dividing the amount in paragraph (G) of this rule by the state hospital's medicaid discharges. Payments will be made on a semiannual basis, based upon the product of each psychiatric hospital per discharge gap amount and medicaid discharges paid during the prior six-month period.

(I) Payments in paragraph (E) of this rule will be paid semiannually and payments in paragraph (F) of this rule will be paid in four installments within the state fiscal year. If the total funds that will be paid to all state hospitals exceeds the aggregate upper payment limit for state hospitals, then the amount paid to all state hospitals will be limited to their proportion of the aggregate upper payment limit.

(J) Supplemental payments to cost-based providers, as specified in rule 5101:3-2-07.1 of the Administrative Code, will be excluded from the cost settlement process.

(K) Hospital payments made under this section, when combined with other payments, shall not exceed te limit specified in 42 C.F.R. 447.271 and 42 C.F.R. 447.272 .

(L) The total funds that will be paid to each hospital will be included in the calculation of disproportionate share limits as decribed in rules 5101:3-2-07.5 and 5101:3-2-10 of the Administrative Code.

Replaces: 5101:3-2-51

Effective: 08/24/2012
R.C. 119.032 review dates: 08/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 511.021, Section 309.30.33 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 7/22/02, 9/1/03, 4/1/09, 4/8/10

5160-2-52 Supplemental inpatient hospital payments for private hospitals.

(A) "Private hospital" means an Ohio hospital, other than a public hospital as defined in rule 5101:3-2-50 of the Administrative Code or a state hospital as defined in rule 5101:3-2-51 of the Administrative Code.

(B) All private hospitals as of October first of the year preceding payments shall be paid supplemental amounts for the provision of hospital inpatient services set forth in this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

(C) Data sources utilized in calculating supplemental payments to private hospitals include the medicare cost report (CMS 2552-96), the Ohio medicaid hospital cost report (JFS 02930, rev. 4/2010), and medicaid management information system (MMIS) inpatient fee-for-service date of service claims data. For state fiscal year (SFY) 2012 and SFY 2013, the hospital fiscal year ending in SFY 2010 medicare cost reports retrieved from the hospital cost report information system and the medicaid MMIS discharges and days data and Ohio medicaid cost report payment data from SFY 2010 will be utilized unless otherwise noted.

(D) The total supplemental payments shall not exceed the amount calculated using the following methodology:

(1) For each private hospital, total medicare costs are divided by total medicare charges to establish the cost-to-charge ratio.

(2) Ohio medicaid payments for the portion of the hospital fiscal year preceeding October 1, 2009 are inflated by five per cent to account for an increase in medicaid payment rates October 1, 2009.

(3) Ohio medicaid charges are multiplied by the cost-to-charge ratio in paragraph (D)(1) of this rule to establish estimated Ohio medicaid costs.

(4) Ohio medicaid costs from paragraph (D)(3) of this rule are inflated using a hospital-specific five year average of medicaid cost per patient day. The average is determined using medicaid cost reports filed in state fiscal years 2005-2009. This hospital-specific inflation factor is applied to individual hospital costs at a discounted rate for the partial year for all hospitals with fiscal year end before the 2010 state fiscal year end of June 30, 2010, plus two years to determine the upper payment limit (UPL) for SFY 2012 and for a third year to determine the UPL for SFY 2013. In the event in which hospital data did not exist for any hospital in years 2005-2009, the state average of 4.43 per cent is utilized. Ohio medicaid costs are multiplied by a factor of 1.01 for the critical access hospitals.

(5) Ohio medicaid payments from paragraph (D)(2) of this rule are then subtracted from the total in paragraph (D)(4) of this rule to determine the inpatient UPL gap for private hospitals. The sum of the differences for these hospitals represents the aggregate UPL gap for all private hospitals.

(E) Private hospitals, excluding children's hospitals defined in rule 5101:3-2-53 of the Administrative Code, that are paid under the inpatient hospital prospective payment system shall receive payments based upon the following hospital-specific calculation:

(1) For each private hospital, calculate a medicare payment-to-charge ratio by dividing total medicare inpatient payments by total medicare inpatient charges.

(2) For each private hospital, calculate the total estimated medicare inpatient payment for medicaid inpatient discharges by multiplying the amount calculated in paragraph (E)(1) of this rule by the total medicaid inpatient charges.

(3) For each private hospital, subtract total inpatient medicaid payments from the amount calculated in paragraph (E)(2) of this rule.

(4) The pooled amount will then be equal to the amount calculated in paragraph (E)(3) of this rule summed across all private hospitals.

(5) From the pool of funds calculated in paragraph (E)(4) of this rule, payments shall be made to all private hospitals based upon the ratio of each private hospital's inpatient medicaid fee-for-service days to the total medicaid fee-for-service inpatient days for all private hospitals. This ratio will be derived from actual patient MMIS fee-for-service date of service claims data in the state fiscal year ending prior to the month of payment.

(F) From a pool of funds calculated in paragraph (D)(5) of this rule less the payments made in paragraph (E)(5) of this rule, private hospitals shall receive payments for the provision of inpatient hospital services. These payments will be based on specialty subgroups according to hospital characteristics that are mutually exclusive and are presented in hierarchical order:

(1) Specialty hospitals, which are freestanding rehabilitation hospitals and freestanding long-term hospitals as defined in 5101:3-2- 07.1 of the Administrative Code.

(2) Critical access hospitals (CAHs), which are private hospitals with a critical access designation.

(3) Rural hospitals, which are private hospitals that are classified by the centers for medicare and medicaid services (CMS) as rural hospitals.

(4) Children's hospitals, which are private hospitals as defined in rule 5101:3-2-53 of the Administrative Code.

(5) "Adult disproportionate share (DSH) hospitals," which are private hospitals with adult high DSH designation as of federal fiscal year 2010.

(6) "Magnet education hospitals," which are private hospitals with an education component which have received magnet designation by the American nurses credentialing center as of December 31, 2010.

(7) "Education hospitals," which are private hospitals with a residency program.

(8) General hospitals paid under the inpatient prospective payment system, which are private hospitals which do not qualify for any of the preceding categories defined in paragraphs (F)(1) to (7) of this rule.

(9) From the specialty hospital subgroup, payments shall be made in the form of a percentage increase applied to hospital-specific SFY 2010 medicaid inpatient fee-for-service payments. This percentage increase will be equal to the pool amount of $14,022,012 in SFY 2012 and $13,396,983 in SFY 2013 divided by total private specialty hospital SFY 2010 medicaid inpatient fee-for-service payments.

(10) For the critical access subgroup defined in paragraph (F)(2) of this rule and the rural subgroup defined in paragraph (F)(3) of this rule, payments shall be made to all CAHs and rural hospitals in the form of a per diem payment applied to hospital-specific SFY 2010 medicaid fee-for-service days. This payment will be equal to the pool amount of $11,819,200 in both SFY 2012 and SFY 2013 divided by the total CAH and rural hospital SFY 2010 medicaid fee-for-service days.

(11) For children's hospitals subgroup defined in paragraph (F)(4) of this rule, payments shall be made in accordance with rule 5101:3-2-53 of the Administrative Code.

(12) For the magnet education subgroup defined in paragraph (F)(6) of this rule, payments shall be made to all magnet education hospitals in the form of a percentage increase applied to hospital-specific SFY 2010 medicaid fee-for-service inpatient payments. This percentage increase will be equal to the pool amount of $12,833,490 in SFY 2012 and $12,282,308 in SFY 2013, divided by total magnet education hospital SFY 2010 medicaid inpatient fee-for-service payments.

(13) For the total education subgroup defined in paragraph (F)(7) of this rule, all education hospitals and magnet education hospitals shall receive a percentage increase in medicaid payments applied to their total hospital-specific SFY 2010 medicaid fee-for-service inpatient payments. This percentage increase will be equal to the pool amount of $40,722,805 in SFY 2012 and $39,534,103 in SFY 2013 divided by total education hospitals' and magnet education hospitals' SFY 2010 medicaid inpatient fee-for-service payments. This amount is in addition to the amount paid to magnet education hospitals in paragraph (F)(12) of this rule.

(14) For the pooled amount calculated in paragraph (D) of this rule less payments made in paragraph (E) of this rule and paragraphs (F)(9) to (F)(13) of this rule, all private hospitals, excluding children's hospitals, shall receive a payment. These payments will be in the form of an additional payment per discharge applied to SFY 2010 inpatient medicaid discharges from the SFY 2010 MMIS date of service claims data. This increase will be equal to the pool amount divided by the total private general acute hospital SFY 2010 medicaid charges. These payments are in addition to the payments in paragraph (E) of this rule and paragraphs (F)(9) to (F)(13) of this rule.

(G) Supplemental payments in paragraph (E) of this rule will be paid semianually and supplemental payments in paragraph (F) of this rule shall be paid in four installments within the state fiscal year.

(H) Supplemental payments to cost-based providers, as specified in rule 5101:5-2-07.1 of the Administrative Code, will be excluded from the cost settlement process.

(I) Hospital payments made under this rule, when combined with other payments made in Chapter 5101:3-2 of the Administrative Code, shall not exceed the limit specified in 42 C.F.R. 447.272 .

(J) The total funds that will be paid to each hospital will be included in the calculation of disproportionate share limits as described in rule 5101:3-2-07.5 of the Administrative Code.

Replaces: 5101:3-2-52

Effective: 08/24/2012
R.C. 119.032 review dates: 08/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , Section 309.30.33 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 4/8/2010

5160-2-53 Supplemental inpatient hospital payments for children's hospitals.

(A) "Children's hospital" means an Ohio hospital as defined in section 3702.51 of the Revised Code that is owned and operated by a private entity and is subject to prospective payment as described in rule 5101:3-2-07.1 of the Administrative Code.

(B) Notwithstanding paragraph (C)(5) of rule 5101:3-2-07.9 of the Administrative Code, children's hospitals will be paid for each cost outlier claim made in fiscal years 2012 and 2013, an amount that is the product of the hospital's allowable charges and the hospital's medicaid inpatient cost-to-charge ratio. The cost-to-charge ratio is based on the medicaid charges as reported on the hospital's medicaid cost report (JFS 02930, rev. 4/2010) and the costs attributable to medicaid as calculated based on the proportion of medicaid charges to total charges on the hospital's interim settled cost report as applied to the claim year.

(C) A children's hospital shall cease being paid for a cost outlier claim under the methodology described in paragraph (B) of this rule and revert to being paid for such a claim according to methodology in paragraph (A)(6) or paragraph (C)(5) of rule 5101:3-2-07.9 of the Administrative Code, as applicable, when the difference between the total amount paid according to the methodology described in paragraph (B) of this rule for such claims and the total amount the director would have paid according to the methodology in paragraph (A)(6) or paragraph (C)(5) of rule 5101:3-2-07.9 of the Administrative Code for such claims, as the applicable paragraph existed on June 30, 2007, does not require the expenditure of the total amount available as described in paragraph (E) of this rule for the applicable fiscal year.

(D) Payments shall be made under paragraph (E) of this rule, if the difference between the total amount the director has paid according to the methodology in paragraph (B) of this rule for cost outlier claims and the total amount the director would have paid in according to the methodology in paragraph (A)(6) or (C)(5) of rule 5101:3-2-07.9 of the Administrative Code for such claims, as the applicable paragraph existed on June 30, 2007, does not require the expenditure of the total amount available as described in paragraph (E) of this rule for the applicable fiscal year.

(E) Up to $28,642,247 in SFY 2012 and up to $27,540,622 in SFY 2013 shall be used to pay the amounts described in paragraph (B) of this rule.

(F) The source data for calculations described in paragraphs (B), (C), and (D) of this rule will be based on claims paid for outliers during the prior state fiscal year.

(G) Payments will be made to children's hospitals on an annual basis, based upon chlidren's hospitals' actual inpatient medicaid fee-for-service outliers derived from actual medicaid discharges paid during the prior state fiscal year and upon the difference between what each hospital would be paid according to the methodology described in paragraph (B) of this rule and the amount the hospital had been paid.

(H) If the supplemental payments to children's hospitals for inpatient outliers do not require the expenditure of the amount described in paragraph (E) of this rule for the supplemental outlier payments and available under the upper payment limit as described by paragraph (B) of this rule, the department would make additional supplemental payments to children's hospitals up to the lesser amount descibed in paragraph (E) of this rule or the amount descibed by paragraphs (B), (C), and (D) of this rule as follows: payments will be made to children's hospitals on an annual basis, based upon children's hospitals actual inpatient medicaid fee-for-service days derived from actual medicaid discharges paid during the prior twelve-month period. If the total funds that would be paid to all children's hospitals exceeds the aggregate upper payment limit for all hospitals, then the amount paid to all children's hospitals will be limited to their proportion of the aggregate upper payment limit.

(I) Hospital payments made under this rule shall not exceed the amount available as described in paragraph (E) of this rule for the applicable fiscal year nor, when combined with other payments made to private hospitals under the state plan, the limit specified in 42 C.F.R. 447.272 . If the total funds that would be paid to all children's hospitals exceeds either of those amounts, then the amount paid to each children's hospital would be its proportion of the lesser of: the amount described by paragraphs (B),(C) and (D) of this rule; or the amount described in pagaraph (E) of this rule. Each hospital's proportion would be equal to the difference between the total amount the director would pay according to the methodology described in paragraph (B) of this rule for such claims minus the total amount the director paid for such claims for that hospital divided by the sum of that amount for children's hospitals.

(J) Hospital payments made under this rule, when combined with other payments made in Chapter 5101:3-2 of the Administrative Code, shall not exceed the limit specified in 42 C.F.R. 447.271 .

(K) The total funds that will be paid to each children's hospital will be included in the calculation of disproportionate share limits as described in rule 5101:3-2-07.5 of the Administrative Code.

Replaces: 5101:3-2-53

Effective: 08/24/2012
R.C. 119.032 review dates: 08/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , Section 309.30.38 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 11/24/05, 4/18/08, 4/8/10

5160-2-54 Supplemental outpatient hospital upper limit payments for private, public non state-owned, and public state-owned hospitals.

(A) Definitions.

(1) "Children's hospital" means an Ohio hospital as defined in section 3702.51 of the Revised Code that is owned and operated by a private entity and is subject to prospective payment as described in rule 5101:3-2-07.1 of the Administrative Code.

(2) Critical access hospitals (CAHs) are hospitals with a critical access designation.

(3) "Private hospital" means an Ohio hospital, other than a public hospital as defined in rule 5101:3-2-50 of the Administrative Code or a state hospital as defined in rule 5101:3-2-51 of the Administrative Code.

(4) "Public hospital" means an Ohio hospital owned and operated by a governmental entity other than the state.

(5) "State hospital" means an Ohio hospital owned and operated by the state.

(B) Supplemental outpatient payments for state hospitals.

(1) State hospitals, as of October first of the year preceding payments, shall be paid supplemental amounts for the provision of hospital outpatient services set forth in paragraph (B) of this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

(2) Data sources used in calculating supplemental payments to state hospitals include the medicare cost report (CMS 2552-96), Ohio medicaid hospital cost report (JFS 02930, rev 4/2010), and medicaid management information system (MMIS) outpatient fee-for-service date of service claims data. For state fiscal years (SFYs) 2012 and 2013, the hospital fiscal year ending in SFY 2010 medicare cost reports retrieved from the hospital cost report information system and Ohio medicaid MMIS outpatient visit date of service claims data and Ohio medicaid cost report payment data from the state fiscal year prior to the month of payment will be utilized unless otherwise noted.

(3) The total supplemental payments shall not exceed the amount calculated using the following methodology:

(a) For each state hospital, total medicare outpatient costs are divided by the total outpatient medicare charges to establish the hospital-specific outpatient cost to charge ratio.

(b) For each state hospital, total Ohio medicaid outpatient charges are multipled by the cost to charge ratio calculated in paragraph (B)(3)(a) of this rule to calculate Ohio medicaid outpatient costs.

(c) The outpatient hospital market basket update value of two point six per cent is applied to each state hospital's Ohio medicaid costs from paragraph (B)(3)(b) of this rule at a discounted rate for hospitals with fiscal year ends prior to 2010 state fiscal year end of June 30, 2010 plus for two years to determine the upper payment limit (UPL) for SFY 2012 and for a third year for SFY 2013. Ohio medicaid outpatient costs are additionally multiplied by a factor of one point zero one for critical access hospitals.

(d) Ohio medicaid outpatient payments for SFY 2010 are then subtracted from the amounts determined in paragraph (B)(3)(c) of this rule to find the outpatient upper payment limit gap. The sum of the differences for these public hospitals represents the total state owned outpatient UPL gap.

(4) From a pool of funds calculated in paragraph (B)(3) of this rule, state hospitals shall receive a percentage increase in outpatient hospital medicaid payments applied to SFY 2010 outpatient hospital medicaid fee-for-service payments. This percentage increase will be equal to the pool amount divided by total state hospital SFY 2010 medicaid outpatient fee-for-service payments. Supplemental payments shall be paid in four installments within the state fiscal year.

(5) Supplemental payments made to cost-based providers will be excluded from the cost settlement process.

(6) Hospital payments made under this section, when combined with other payments made under the state plan shall not exceed the limit specified in 42 C.F.R. 447.321 .

(7) The total funds that will be paid to each hospital will be included in the calculation of disproportionate share limits as described in rule 5101:3-2-07.5 of the Administrative Code.

(C) Supplemental outpatient payments for public hospitals.

(1) Public hospitals as of October first of the year preceding payments shall be paid supplemental amounts for the provision of hospital outpatient services set forth in paragraph (C) of this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

(2) Data sources used in calculating supplemental payments to public hospitals include the medicare cost report (CMS 2552-96), Ohio medicaid hospital cost report (JFS 02930, rev. 4/2010), and medicaid MMIS inpatient fee-for-service date of service claims data. For SFYs 2012 and 2013, the hospital fiscal year ending in SFY 2010 medicare cost reports retrieved from the hospital cost report information system and medicaid MMIS outpatient visit date of service claims data and Ohio medicaid cost report payment data from the state fiscal year prior to the month of payment will be utilized unless otherwise noted.

(3) The total supplemental payments shall not exceed the amount calculated using the following methodology:

(a) For each public hospital, total medicare outpatient costs are divided by the total outpatient medicare charges to establish the hospital-specific outpatient cost to charge ratio.

(b) For each public hospital, total Ohio medicaid outpatient charges are multiplied by the cost to charge ratio calculated in paragraph (C)(3)(a) of this rule to calculate Ohio medicaid outpatient costs.

(c) The outpatient hospital market basket update value of two point six per cent is applied to Ohio medicaid outpatient costs from paragraph (C)(2)(b) of this rule at a discounted rate for hospitals with fiscal year end prior to 2010 state fiscal year end June 30, 2010 plus for two years to determine the UPL for SFY 2012 and for a third year for SFY 2013. Ohio medicaid outpatient costs are additionally multiplied by one point zero one for the critical access hospitals.

(d) Ohio medicaid outpatient payments for SFY 2010 are then subtracted from the amounts determined in paragraph (C)(3)(c) of this rule to find the outpatient UPL gap. The sum of the differences for these public hospitals represents the total public hospital UPL gap.

(4) From the pool amount determined in paragraph (C)(3)(d) of this rule, up to $3,673,852 in both SFY 2012 and SFY 2013 shall be used to make supplemental payment to all public hospitals paid under the outpatient prospective payment system. Each hospital payment will be equal to the pool amount calculated in paragraph (C)(3)(d) of this rule multiplied by the hospital-specific ratio of each hospital's outpatient medicaid fee-for-service visits to the total medicaid outpatient fee-for-service visits for all public hospitals. Supplemental payments under this paragraph shall be paid semianually.

(5) From the pool amount calculated in paragraph (C)(3)(d) of this rule less payments made in paragraph (C)(4) of this rule, public hospitals with fewer than two hundred hospital beds shall receive a percentage increase applied to SFY 2010 outpatient medicaid fee-for-service payments. This percentage increase will be equal to the pool amount divided by the total small public non-state hospital SFY 2010 medicaid outpatient fee-for-service payments. Supplemental payments under this section shall be paid in four installments within the state fiscal year.

(6) Supplemental payments made to cost-based providers will be excluded from the cost settlement process.

(7) Hospital payments made under the state plan, when combined with other payments made under Chapter 5101:3-2 of the Administrative Code, shall not exceed the limit specified in 42 C.F.R. 447.321 .

(8) The total funds that will be paid to each hospital will be included in the calculation of disproportionate share limits as described in rule 5101:3-2-07.5 of the Administrative Code.

(D) Supplemental payments for private hospitals.

(1) All private hospitals as of October first of the year preceding payments shall be paid supplemental amounts for the provision of outpatient hospital services set forth in paragraph (D) of this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

(2) Data sources used in calculating supplemental payments to private hospitals include the medicare cost report (CMS 2552-96), the Ohio medicaid cost report (JFS 02930, rev. 4/2010), and medicaid management information system (MMIS) outpatient fee-for-service date of service claims data. For state fiscal years (SFYs) 2012 and 2013, the hospital fiscal year ending in SFY 2010 medicare cost reports retrieved from the hospital cost report information system and medicaid MMIS outpatient visit date of service claims data and Ohio medicaid cost report payment data from the state fiscal year prior to the month of payment will be utilized unless otherwise noted.

(3) The total supplemental payments shall not exceed the amount calculated using the following methodology:

(a) For each private hospital, total medicare outpatient costs are divided by the total outpatient medicare charges to establish the hospital-specific cost to charge ratio.

(b) For each private hospital, total Ohio medicaid outpatient charges are multiplied by the cost to charge ratio calculated in paragraph (D)(3)(a) of this rule to calculate Ohio medicaid outpatient costs.

(c) The outpatient hospital market basket update value of two point six per cent is applied to Ohio medicaid outpatient costs from paragraph (D)(3)(b) of this rule at a discounted rate for hospitals with fiscal year end prior to 2010 state fiscal year end June 30,2010 plus two years to determine the UPL for SFY 2012 and for a third year for SFY 2013. Ohio medicaid costs are additionally multiplied by a factor of one point zero one for the critical access hospitals.

(d) Ohio medicaid outpatient hospital payments for state fiscal year 2010 are then subtracted from the amounts determined in paragraph (D)(3)(d) of this rule to find the outpatient UPL gap. The sum of the differences for these private hospitals represents the total privately-owned outpatient UPL gap.

(4) From the pool amount determined in paragraph (D)(3)(d) of this rule, up to $11,806,618 in both SFY 2012 and SFY 2013, shall be made to all private hospitals paid under the outpatient prospective payment system, except children's hospitals as defined in paragraph (A)(1) of this rule. The payment will be equal to the pool amount multipled by the ratio of each private Ohio hospital paid under the outpatient prospective payment system outpatient medicaid fee-for-service visits to the total outpatient medicaid fee-for-service encounters for all Ohio private hospitals paid under the outpatient prospective payment system.

(5) From the pool amount calculated in paragraph (D)(3)(d) of this rule, less payments made in paragraph (D)(4) of this rule, private hospitals will be paid the following supplemental payments for the provision of hospital outpatient services. All private hospitals shall receive a percentage increase applied to total SFY 2010 medicaid outpatient fee-for-service payments. This percentage increase will be equal to the pool amount divided by total private hospital SFY 2010 medicaid outpatient fee-for-service payments.

(6) Supplemental payments in paragraph (D)(4) of this rule shall be paid semiannually and supplemental payments in paragraph (D)(5) of this rule shall be paid in four installments within the state fiscal year.

(7) Supplemental payments made to cost-based providers will be excluded from the settlement process.

(8) Hospital payments made under this paragraph, when combined with other payments made under the state plan shall not exceed the limit specified in 42 C.F.R. 447.321 .

(9) The total funds that will be paid to each hospital will be included in the calculation of disproportionate share limits as described in rule 5101:3-2-07.5 of the Administrative Code.

Replaces: 5101:3-2-54

Effective: 08/24/2012
R.C. 119.032 review dates: 08/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , Section 309.30.33 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 4/8/10

5160-2-65 Inpatient hospital reimbursement.

Effective for dates of discharge on or after July 1, 2013, hospitals defined as eligible providers of hospital services in rule 5160-2-01 of the Administrative Code and not defined in paragraph (A) of this rule are subject to the all patient refined diagnosis related groups (APR-DRG) and prospective payment methodology utilized by the Ohio department of medicaid as described in this rule.

Unless otherwise referenced in this rule, rules 5160-2- 07.1, 5160-2- 07.3, 5160-2- 07.4, 5160-2- 07.8, 5160-2- 07.9 and 5160-2- 07.11 of the Administrative Code apply only to inpatient hospital claims for discharges occurring on or before June 30, 2013.

(A) Excluded hospitals. Services provided by the following institutions are not subject to the APR-DRG reimbursement system:

(1) "Freestanding rehabilitation hospitals" excluded from medicare prospective payment in accordance with 42 CFR 412.23(b) effective October 1, 2003;

(2) "Freestanding long-term hospitals" excluded from medicare prospective payment in accordance with 42 CFR 412.23(e) effective October 1, 2003;

(3) Hospitals that are excluded from medicare prospective payment due to providing services, in total, which are excluded due to a combination of the provisions of paragraphs (A)(1) and (A)(2) of this rule;

(4) Cancer hospitals as defined in rule 5160-2- 07.2 of the Administrative Code for discharges on and after July 1, 1992.

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

(1) Teaching hospitals as defined in rule 5160-2- 07.2 of the Administrative Code that are located in Ohio.

(2) Teaching hospitals as defined in rule 5160-2- 07.2 of the Administrative Code that are not located in Ohio.

(3) Children's hospitals as defined in rule 5160-2- 07.2 of the Administrative Code that are located in Ohio.

(4) Children's hospitals as defined in rule 5160-2- 07.2 of the Administrative Code that are not located in Ohio.

(5) Rural referral center hospitals as defined in rule 5160-2- 07.2 of the Administrative Code that are located in Ohio.

(6) Metropolitan statistical area (MSA) hospitals as defined in rule 5160-2- 07.2 of the Administrative Code that are located in Ohio.

(7) Non-MSA hospitals as defined in rule 5160-2- 07.2 of the Administrative Code that are located in Ohio.

(8) Hospitals that are not located in Ohio that are not classified in paragraph (B)(2) or (B)(4) of this rule.

(C) Classification procedures are as described in rule 5160:2- 07.2 of the Administrative Code.

(D) DRG/severity of illness assignment.

(1) Each discharge on or after July 1, 2013 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 required by the APR-DRG grouper, then the claim will be denied payment by the department.

(E) Payment formula.

(1) The formula used in the APR-DRG prospective payment system effective for dates of discharge on or after July 1, 2013 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 (H) of this rule multiplied by the corresponding relative weight for the DRG/SOI as described in paragraph (I) of this rule.

(b) Capital allowance equals the per case add-on as described in paragraph

(K) of this rule.

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

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

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

(F) 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 payment except as provided in rule 5160-2-24 of the Administrative Code. Except as provided in rules 5160-2-24, 5160-2- 07.13, 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.

(G) Sources for inputs in the payment formula.

(1) The dataset used as inputs in the payment formula and determination of relative weights established for discharges on or after July 1, 2013 consists of:

(a) Inpatient hospital claims with dates of discharge from October 1, 2008 through September 30, 2010;

(b) Cost reports submitted by hospitals to the department on its medicaid cost report for the hospital years that end in state fiscal years 2009 (JFS 02930 rev. 4/2009), 2010 (JFS 02930 rev. 4/2010) and 2011 (JFS 02930 rev. 4/2011); and

(c) Inflation factors computed for Ohio by a nationally-recognized research firm that computes similar factors for the medicare program.

(2) The inflation factors were used to apply an inflationary value to the total cost computed for each case inflating it to September 30, 2013.

(H) Computation of hospital base rate.

(1) Except as described in paragraph (H)(4) of this rule, the base rate for each Ohio children's hospital is equal to:

(a) Ninety-nine and five 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 (H)(3) of this rule.

(2) Except as described in paragraph (H)(4) of this rule, the base rate for hospitals in Ohio peer groups other than Ohio children's hospitals is equal to:

(a) Sixty-four and five hundredths 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 (H)(3) of this rule.

(c) For dates of service on or after January 1, 2014, the amount will be equal to ninety-five per cent of the amount calculated in paragraph (H)(2)(a) and (H)(2)(b) of this rule.

(3) 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.

(4) For non-Ohio hospital peer groups, the peer group base rate is equal to the value assigned to the peer group effective January 1, 2013. For dates of service on or after January 1, 2014, the amount will be equal to ninety-five per cent of the base rate in effect on January 1, 2013.

(5) Peer group risk corridors.

Effective for discharges on or after July 1, 2013 and on or before June 30, 2016, the department will apply the following:

(a) If a hospital is in a non-MSA peer group, in the rural referral center peer group, or is in a MSA peer group but has a medicare designation as a critical access hospital, then the hospital's base rate is equal to the greater of:

(i) The peer group base rate; or

(ii) Seventy per cent of the computed costs of the hospital's cases.

(b) If a hospital is in a MSA peer group and is not a medicare designated critical access hospital, then the hospital's base rate is equal to:

(i) The peer group base calculated in paragraph (H)(2) of this rule, if the peer group base rate does not result in more than a three per cent reduction or gain in payments compared to the DRG prospective payment system in effect prior to July 1, 2013; or

(ii) A hospital-specific base rate established to ensure the new peer group base rate does not result in more than a three per cent reduction or gain in payments compared to the prior DRG prospective payment system.

(iii) For discharges on or after July 1, 2014 the risk corridor shall be adjusted to be no more than a five per cent reduction or gain.

(iv) For discharges on or after July 1, 2015 the risk corridor shall be adjusted to be no more than an eight per cent reduction or gain.

(c) If the hospital is in the teaching hospital peer group, then the hospital's base rate is equal to:

(i) The peer group base rate unless it was found that the new peer group base rate would result in a reduction or more than a three per cent gain in payments from the prior DRG prospective payment system; or

(ii) A hospital-specific base rate established to ensure that the new peer group base rate does not result in a reduction or more than a three per cent gain in payments compared to the prior DRG prospective payment system.

(d) If the hospital is in a children's hospital peer group, then the hospital's base rate is equal to:

(i) The hospital base rate calculated in paragraph (H)(1) of this rule, if the base rate does not result in more than a five per cent reduction or gain in payments compared to the prior DRG prospective payment system; or

(ii) A hospital-specific base rate established to ensure the new peer group base rate does not result in more than a five per cent reduction or gain in payments compared to the prior DRG prospective payment system.

(e) If the hospital is a psychiatric hospital owned and operated by the state of Ohio, regardless of peer group, then the hospital's base rate is equal to;

(i) The hospital base rate calculated in paragraph (H)(1) of this rule, if the peer group base rate does not result in a reduction in payments compared to the prior DRG prospective payment system; or

(ii) A hospital-specific base rate established to ensure the new peer group base rate does not result in a reduction.

(I) Computation of relative weights. The relative weight 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.

(J) Computation of outlier payments.

(1) If a discharge is eligible for an outlier payment, then the payment is equal to ninety-five per cent of the value of eligible outlier costs. For dates of service on or after January 1, 2014, the payment will be equal to ninety 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 (E)(1)(a) of this rule plus a fixed outlier threshold as described in paragraph (J)(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 forty-two thousand nine hundred dollars. The fixed outlier threshold for DRGs other than neonate and tracheostomy DRGs billed by hospitals in a children's peer group or the teaching peer group is fifty-four thousand four hundred dollars. The fixed outlier threshold for cases other than neonate and tracheostomy billed by hospitals among other peer groups is sixty-eight thousand dollars.

(3) For any claim that qualifies for an outlier payment, the final claim payment shall be limited to the lessor of covered billed charges or the total payment calculated in paragraph (E)(1) of this rule.

(K) Computation of capital payments.

(1) For Ohio hospitals, a capital allowance will be paid as described in rule 5160-2- 07.6 of the Administrative Code.

(2) For non-Ohio hospitals a capital allowance will be paid as described in rule 5160-2- 07.6 of the Administrative Code.

(3) Hospitals serving recipients enrolled in a medicaid managed care plan shall be paid a capital allowance that it is determined based on a hospital's medicaid managed care service experience as published by the department. Non-Ohio hospitals shall be paid a capital allowance using the published statewide average managed care capital rate.

(L) Computation of medical education payments.

For Ohio hospitals that have an approved medical education program as defined in rule 5160-2- 07.7 of the Administrative Code, an education allowance amount is added. The medical education allowance amount is described in rule 5160-2- 07.7 of the Administrative Code adjusted to ensure payment neutrality for medical education with the adoption of the APR-DRG payment system described in this rule. For dates of service on or after January 1, 2014, the medical education payments for all hospitals except Ohio children's hospitals will be equal to ninety-five per cent of the amount described in this paragraph.

(1) If a hospital had modeled medical education payments that were less than the medical education payments received for the same discharges upon initial payment, then the hospital's medical education allowance was adjusted upward so that, when multiplied by the new relative weights, the payments yielded payment neutrality on the medical education payment component alone.

(2) If a hospital had modeled medical education payments that were more than the medical education payments received for the same discharges upon initial payment, then no adjustment was made to the medical education allowance rate for the hospital.

(M) 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 the department.

(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 the department. 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.

(N) Other payment policies.

(1) In accordance with rule 5160-2-03 of the Administrative Code, no coverage is available for days of inpatient care which occur solely for the provision of rehabilitation services related to a chemical dependency.

(2) 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 are not required to 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.

(3) 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- 07.13 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 (E) of this rule. When a patient is transferred, the department'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.

(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 (N)(3) 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, the department requires hospitals to submit separate claims based respectively on the mother's individual eligibility and the child's individual eligibility.

Effective: 03/27/2014
R.C. 119.032 review dates: 09/01/2018
Promulgated Under: 119.03
Statutory Authority: 5162.03
Rule Amplifies: 5162.03 , 5164.02 , 5164.70
Prior Effective Dates: 7/1/13 (Emer.), 9/27/13