Chapter 5160-57 Medicaid Provider Incentive Program

5160-57-01 Medicaid provider incentive program (MPIP): program eligibility requirements.

(A) The medicaid provider incentive program (MPIP) is Ohio's program for implementing section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, and the published regulations at 42 C.F.R. Part 495 (as in effect on January 1, 2013) that establish a program that permits certain eligible professionals and eligible hospitals participating in medicaid programs to receive incentive payments if they are meaningful users of certified electronic health record (EHR) technology. The incentive payments are not a reimbursement, but are intended to encourage eligible professionals and eligible hospitals to adopt, implement, or upgrade to certified EHR technology and use it in a meaningful manner. MPIP incentive payments will only be made as long as federal funds are available.

(B) The following medicaid providers are eligible to participate in MPIP:

(1) Medicaid eligible professionals; and

(2) Medicaid eligible hospitals.

(C) Medicaid eligible professionals:

(1) Eligible professionals participating in Ohio's MPIP program are subject to the program eligibility rules and regulations published at 42 C.F.R. Part 495 (as in effect on January 1, 2013).

(2) An eligible professional is limited to the following types of providers, consistent with the scope of practice as it is recognized under Ohio law as applicable for each type of professional:

(a) Physicians, including optometrists, in accordance with rule 5101:3-4-01 of the Administrative Code.

(b) Dentists.

(c) Advanced practice nurses as defined in section 4723.43 of the Revised Code.

(d) Physician assistants (PA) practicing in a federally qualified health center (FQHC) or a rural health clinic (RHC) that is so led by a PA. "So led" means the PA is the primary provider in a clinic (for example, when there is a part-time physician and the PA is full-time, the PA will be considered as the primary provider); the PA is a clinical or medical director at a clinical site or practice; or the PA is an owner of an RHC.

(3) An eligible professional must, for each year of participation in MPIP:

(a) Be an enrolled Ohio medicaid provider with an active Ohio medicaid provider agreement.

(b) Not have received an EHR incentive payment within the current payment year from:

(i) Another state;

(ii) MPIP; or

(iii) The medicare EHR incentive payment program.

(c) Not have a current sanction or exclusion identified at:

(i) The United States department of health and human services, office of inspector general, list of excluded individuals and entities: or

(ii) The Ohio list of excluded providers.

(D) Medicaid eligible hospitals.

(1) Eligible hospitals participating in Ohio's MPIP program are subject to the program eligibility rules and regulations published at 42 C.F.R. Part 495 (as in effect on January 1, 2013).

(2) An eligible hospital must be one of the following:

(a) An acute care hospital where the average length of stay is twenty-five days or fewer (acute care hospital's average length of stay will be calculated based on the hospital's fiscal year); and has a federal centers for medicare and medicaid services (CMS) certification number that has the last four digits in the series 0001-0879 or 1300-1399.

(b) Cancer hospitals and critical access hospitals are included in the definition of an acute care hospital and will be eligible for MPIP if they meet the requirements of an acute care hospital as defined in this rule.

(c) A children's hospital that is separately certified and is either freestanding or a hospital-within-a hospital that has a CMS certification number with the last four digits in the series 3300-3399 and predominantly treats individuals under the age of twenty-one.

(3) An eligible hospital must, for each year of participation in MPIP:

(a) Be an enrolled Ohio medicaid provider with an active Ohio medicaid provider agreement.

(b) Not have received an EHR incentive payment, within the current payment year, from:

(i) Another state; or

(ii) MPIP.

(c) Not have a current sanction or exclusion identified at:

(i) The United States department of health and human services, office of inspector general, list of excluded individuals and entities; or

(ii) The Ohio list of excluded providers.

(E) Establishing patient volume.

(1) Eligible professionals and eligible hospitals must annually meet patient volume requirements in accordance with 42 C.F.R. 495.304 paragraphs (c) to (f) (as in effect on January 1, 2013). Childrens hospitals as defined in paragraph (D)(2)(c) of this rule are exempt from meeting medicaid patient volume requirements.

(2) Patient volume is calculated in accordance with the patient encounter methodology defined in 42 C.F.R. 495.306(c) (as in effect on January 1, 2013).

(3) For purposes of MPIP only, a pediatrician means a medical doctor, who diagnoses, treats, examines, and prevents diseases and injuries in children. A pediatrician must hold a doctor of medicine (MD) or doctor of osteopathy (DO) degree and hold a current, in good-standing board certification in pediatrics through the American board of pediatrics, the American board of surgery, the American board of radiology, the American board of urology or the American osteopathic board of pediatrics or a current, in good standing, pediatric subspecialty certificate recognized by the American board of medical specialties.

(F) Encounters.

(1) Encounters are defined in accordance with 42 C.F.R. 495.306(e) (as in effect on January 1, 2013).

(2) Out-of-state encounters.

(a) An eligible professional and eligible hospital may use out-of-state medicaid encounters for calculating patient volume.

(b) "Out-of-state encounters" are services rendered by an eligible professional or eligible hospital to a non-Ohio resident that meets the definitions of an encounter as defined in paragraph (F) of this rule.

(c) If out-of-state medicaid encounters are included in the numerator then all out-of-state encounters, for the same representative time period, should be included in the denominator.

(d) Eligible professionals and eligible hospitals are required to provide documentation to support the use of out-of-state encounters and must report each state's out-of-state encounters separately through the MPIP system, in a manner specified by the Ohio department of medicaid (ODM).

(G) Group practice or clinic patient volume proxy.

(1) A group practice or clinic will be permitted to calculate patient volume at the group practice or clinic level, but only in accordance with all of the following limitations defined in 42 C.F.R. 495.306(h) (as in effect on January 1, 2013):

(a) The group practice or clinic's patient volume is appropriate as a patient volume methodology calculation for the eligible professional.

(b) There is an auditable data source to support the group practice's or clinic's patient volume determination.

(c) All eligible professionals in the group practice or clinic must use the same methodology for the payment year.

(d) The group practice or clinic must use the entire practice's or clinic's patient volume and not limit patient volume in any way.

(e) If an eligible professional works inside and outside of the group practice or clinic, the patient volume calculation includes only those encounters associated with the group practice or clinic, and not the eligible professional's outside encounters.

(2) To calculate patient volume at the group practice or clinic level, all medicaid eligible professionals, (as defined in paragraph (C) of this rule), of the group practice or clinic must be an enrolled Ohio medicaid provider with an active Ohio medicaid provider agreement.

(3) Each group practice or clinic must confirm in writing, in a manner specified by ODM, from each eligible professional in the group practice or clinic, that the eligible professional is consenting to one of the following:

(a) Attesting as a member of the group practice or clinic and permitting the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation; or

(b) Not attesting as a member of the group practice or clinic but will permit the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation.

(4) Evidence of an eligible professional's consent must be provided for processing through the MPIP system and must include the following information:

(a) The group practice or clinic name and medicaid ID number;

(b) The name and medicaid ID number of each eligible professional in the group; and

(c) Must specify if each eligible professional is consenting to the use of his or her encounters as defined in paragraphs (G)(3)(a) and (G)(3)(b) of this rule.

(5) If an eligible professional is not attesting as a member of a group practice or clinic but will permit a group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice or clinic, the non-participating eligible professional cannot use those encounters toward his or her individual patient volume calculation.

(6) If any eligible professional within the group practice or clinic does not provide written consent for the group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice of clinic, the group practice or clinic is precluded from using a group practice or clinic patient volume proxy.

(7) Supporting documentation must be provided for processing through the MPIP system of the attested patient volume proxy and include the medicaid encounters, total encounters, name and medicaid ID of all medicaid practitioners used in the group practice or clinic patient volume proxy calculation. This information shall be provided in a manner specified by ODM.

(8) Eligible professionals must be employed by the group practice or clinic at the time of attestation in order to use the group practice's or clinic's patient volume proxy.

(H) Meaningful use (MU)

(1) Eligible professionals and eligible hospitals must:

(a) Meet all activities required to receive an incentive payment in accordance with 42 C.F.R. 495.314 (as in effect on January 1, 2013), in addition to all program eligibility requirements.

(b) Report which certified EHR technology they have adopted, implemented or upgraded to by providing supporting documentation through the MPIP system at the time of registration and attestation, in a manner specified by ODM.

(c) Select an EHR reporting period and meet the definition of meaningful EHR user as defined in 42 C.F.R. 495.4 (as in effect on January 1, 2013).

(d) Meet the MU criteria established in 42 C.F.R. 495.6 (as in effect on January 1, 2013).

(e) Demonstrate that meaningful use objectives and measures are met, in accordance with 42 C.F.R. 495.8 (as in effect on January 1, 2013).

(2) Demonstration of MU is subject to review by both ODM and CMS.

(3) Dual eligible hospitals meeting MU criteria for the medicare EHR incentive program will be deemed meaningful users for MPIP, but will be required to meet additional MPIP program eligibility requirements.

Replaces: Part of 5101:3-57-02

Effective: 10/01/2013
R.C. 119.032 review dates: 08/05/2018
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215
Prior Effective Dates: 1/1/2012

5160-57-02 [Rescinded] Medicaid provider incentive program (MPIP): certified electronic health record technology requirements, adopt, implement, or upgrade and meaningful use stage one.

Effective: 10/01/2013
R.C. 119.032 review dates: 06/18/2013
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215
Prior Effective Dates: 01/01/2012

5160-57-03 Medicaid provider incentive program (MPIP): incentive payments (calculation, duration, amount and limit).

(A) Medicaid provider incentive program (MPIP) incentive payments.

(1) All MPIP incentive payments will be calculated in accordance with 42 C.F.R. 495.310 (as in effect on January 1, 2013).

(2) An eligible professional or eligible hospital will be eligible to receive the federally specified incentive payment amount, regardless of the purchase or implementation costs of their electronic health record (EHR) system as long as the eligible professional or eligible hospital meets all MPIP program eligibility requirements as specified in Chapter 5101:3-57 of the Administrative Code.

(3) In no case may any medicaid eligible professional or eligible hospital receive an incentive payment after payment year 2021.

(B) Eligible professional incentive payments.

(1) Reassignment of payment.

(a) Assignment of the incentive payment must be consistent with federal and state medicaid laws, rules, and regulations, (including without limitation, fraud, waste, and abuse laws rules and regulations).

(b) Eligible professionals may reassign incentive payments to an employer or entity with which the eligible professional has a valid contractual arrangement allowing the employer or entity to bill for and receive payment for the eligible professional's covered professional services. The employer or entity for which payment is reassigned must be an Ohio medicaid provider with an active Ohio medicaid provider agreement.

(c) An eligible professional may not reassign an incentive payment to more than one employer or entity. In cases where eligible professionals are associated with more than one practice, the eligible professional must select one tax identification number to receive any applicable EHR incentive payment.

(C) Eligible hospital incentive payments.

(1) All data used to calculate the hospital EHR incentive payment amount must be provided through the MPIP system at the time of the eligible hospital's application and attestation, in a manner specified by the Ohio department of medicaid (ODM).

(2) All eligible hospital calculations of the aggregate EHR hospital incentive payment made at the time of MPIP application are subject to review and may be adjusted based on review findings.

(3) An eligible hospital may be paid up to one hundred per cent of the calculated aggregate EHR incentive amount over a four-year period, if it meets all MPIP program eligibility requirements: forty per cent in year one; thirty per cent in year two; twenty per cent in year three; and ten per cent in year four.

(4) An eligible hospital may not alter or modify data elements used to calculate the hospital EHR incentive payment after MPIP has processed an eligible hospitals application for payment and payment has been disbursed for the payment year.

(D) Issuance of payments.

(1) MPIP incentive payment will be issued and disbursed in compliance with 42 C.F.R. 495.312 (as in effect on January 1, 2013).

(2) Payments will be made to the taxpayer identification number selected at the time of registration.

(E) Offsets, adjustments and recoupment of payment.

(1) MPIP payments are subject to offsets, adjustments and recoupments. These and/or other collection methods will be applied to the medicaid EHR incentive payments to reimburse or pay for medicaid overpayments, fines, penalties, or other debts owed by the provider or its assignee(s) to the medicaid state agency, Ohio county or local governments, the department of health and human services, or any other federal agency.

(2) ODM will identify and recoup overpayments made under the incentive program that result from incorrect or fraudulent attestations, quality measures, cost data, patient data, or any other submission required to establish eligibility or qualify for a payment.

(3) Eligible professionals and eligible hospitals must report any suspected overpayments of an incentive payment to ODM within sixty days of its discovery.

Effective: 10/01/2013
R.C. 119.032 review dates: 08/05/2018
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215
Prior Effective Dates: 1/1/12, 09/10/2012

5160-57-04 Medicaid provider incentive program (MPIP): program integrity and provider appeals.

(A) Program integrity.

(1) MPIP legal notice.

(a) All eligible professionals and eligible hospitals submitting an application to receive an MPIP payment are required to sign the MPIP legal notice before confirming and submitting their application.

(b) All program applicants are bound by the requirements of the MPIP legal notice.

(2) Eligible professional and eligible hospital MPIP applications and attestations are subject to verification by the Ohio department of medicaid (ODM).

(3) For any given payment year an eligible professional and eligible hospital must register for MPIP by the end of the calendar year (CY) for an eligible professional and federal fiscal year (FFY) for an eligible hospital.

(4) An eligible professional and eligible hospital will have sixty days after the end of the CY for an eligible professional and FFY for and eligible hospital to complete attestation via the MPIP system for a given payment year.

(5) Post payment audits and record retention.

(a) An eligible professional's and eligible hospital's MPIP application and attestation are subject to a post payment audit.

(b) ODM or its designee, the state auditor's office, the state attorney general's office and the federal centers for medicare and medicaid services (CMS) may conduct reviews and audits of MPIP applications for the purpose of determining compliance with the requirements of this chapter as well as with applicable state and federal requirements.

(c) Audits and reviews may be conducted on-site as determined necessary based on periodic analysis of medical, financial, and other information.

(d) Records stored electronically must be produced at the eligible professional's or eligible hospital's expense, upon request, in the format specified by ODM.

(e) All records must be maintained for a minimum of seven years following the last day of the CY for eligible professionals or FFY for eligible hospitals in which payment related to the attestation has been received, or in the event that the eligible professional or eligible hospital has been notified that state or federal authorities have commenced an audit or investigation of their MPIP application, until such time as the matter under audit, appeal or investigation has been resolved.

(f) An eligible professional and eligible hospital must comply with all audit recoveries.

(6) Fraud, waste, and abuse.

(a) Suspicion or detection of fraud and abuse by ODM will be referred to the medicaid fraud control unit (MFCU) in the office of the attorney general (AG). Referrals to the MFCU will be investigated for prosecutorial merit.

(b) Substantiated cases of fraud and abuse will be prosecuted according to federal and state regulations.

(B) Provider appeals.

(1) An eligible professional or eligible hospital may appeal the following issues related to MPIP, by first requesting an informal review:

(a) Incentive payment amounts.

(b) Provider eligibility determinations (i.e. patient volume, hospital-based).

(c) Demonstration of adoption, implementation, or upgrade, and meaningful use eligibility.

(2) Appeals filed after the deadlines specified in paragraphs (B)(3)(a) and (B)(4)(a) of this rule, will be dismissed without the ability to refile. If the deadline falls on a saturday, sunday, state or federal holiday, the period for requesting an appeal will be extended to the next business day.

(3) Informal review.

(a) If the MPIP system has made a preliminary determination that may be adverse regarding the incentive payment application of an eligible professional or eligible hospital, the eligible professional or eligible hospital may request an informal review of the preliminary determination via the MPIP system, within fifteen calendar days of notification of an adverse preliminary determination.

(b) A request for informal review shall be made via the MPIP system and may include supporting documentation to support the request.

(c) An eligible professional or eligible hospital will be notified of the informal review decision via email and will be advised to log into the MPIP system to see the details of the review decision.

(d) An eligible professional or eligible hospital may withdraw the request for an informal review via the MPIP system, without reason, at any time, after the initial filing and before an informal review decision is issued.

(4) Request for reconsideration.

(a) If the informal review upholds the preliminary adverse determination and the eligible professional or eligible hospital does not agree with the informal review decision, the eligible professional or eligible hospital may submit a written request for reconsideration no later than fifteen calendar days after the date of notification of determination via the MPIP system.

(b) The request for reconsideration shall be initiated via the MPIP system and must include a written and signed letter from the eligible professional or eligible hospital containing the following information:

(i) Clear identification of the affected eligible professional or eligible hospital;

(ii) The proposed action being contested;

(iii) The basis for requesting reconsideration; and

(iv) Supporting documentation being submitted.

(c) The written request for reconsideration must be signed, dated, include any supporting documentation and must be uploaded via the MPIP system.

(d) An eligible professional or eligible hospital will be notified in writing, by certified mail, of the reconsideration decision.

(5) In accordance with Chapter 2505. of the Revised Code, an eligible professional or eligible hospital may appeal the reconsideration decision by filing a notice of appeal with the court of common pleas of Franklin county. The notice shall identify the decision being appealed and the specific grounds for the appeal. The notice of appeal shall be filed not later than fifteen days after the department mails its notice of the reconsideration decision. A copy of the notice of appeal shall be filed with the department not later than three days after the notice is filed with the court.

Effective: 10/01/2013
R.C. 119.032 review dates: 08/05/2018
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215
Prior Effective Dates: 1/1/12, 09/10/2012