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Ohio Laws and Rules
Chapter 5124: INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES SERVICES
As used in this chapter:
(A) "Affiliated operator" means an operator affiliated with either of the following:
(1) The exiting operator for whom the affiliated operator is to assume liability for the entire amount of the exiting operator's debt under the medicaid program or the portion of the debt that represents the franchise permit fee the exiting operator owes;
(2) The entering operator involved in the change of operator with the exiting operator specified in division (A)(1) of this section.
(B) "Allowable costs" means an ICF/IID's costs that the department of developmental disabilities determines are reasonable. Fines paid under section 5124.99 of the Revised Code are not allowable costs.
(C) "Capital costs" means an ICF/IID's costs of ownership and costs of nonextensive renovation.
(D) "Case-mix score" means the measure determined undersection 5124.192 of the Revised Code of the relative direct-care resources needed to provide care and habilitation to an ICF/IID resident.
(E) "Change of operator" means an entering operator becoming the operator of an ICF/IID in the place of the exiting operator.
(1) Actions that constitute a change of operator include the following:
(a) A change in an exiting operator's form of legal organization, including the formation of a partnership or corporation from a sole proprietorship;
(b) A transfer of all the exiting operator's ownership interest in the operation of the ICF/IID to the entering operator, regardless of whether ownership of any or all of the real property or personal property associated with the ICF/IID is also transferred;
(c) A lease of the ICF/IID to the entering operator or the exiting operator's termination of the exiting operator's lease;
(d) If the exiting operator is a partnership, dissolution of the partnership;
(e) If the exiting operator is a partnership, a change in composition of the partnership unless both of the following apply:
(i) The change in composition does not cause the partnership's dissolution under state law.
(ii) The partners agree that the change in composition does not constitute a change in operator.
(f) If the operator is a corporation, dissolution of the corporation, a merger of the corporation into another corporation that is the survivor of the merger, or a consolidation of one or more other corporations to form a new corporation.
(2) The following, alone, do not constitute a change of operator:
(a) A contract for an entity to manage an ICF/IID as the operator's agent, subject to the operator's approval of daily operating and management decisions;
(b) A change of ownership, lease, or termination of a lease of real property or personal property associated with an ICF/IID if an entering operator does not become the operator in place of an exiting operator;
(c) If the operator is a corporation, a change of one or more members of the corporation's governing body or transfer of ownership of one or more shares of the corporation's stock, if the same corporation continues to be the operator.
(F) "Cost center" means the following:
(1) Capital costs;
(2) Direct care costs;
(3) Indirect care costs;
(4) Other protected costs.
(G) "Costs of nonextensive renovations" means the actual expense incurred by an ICF/IID for depreciation or amortization and interest on renovations that are not extensive renovations.
(1) "Costs of ownership" means the actual expenses incurred by an ICF/IID for all of the following:
(a) Subject to division (H)(2) of this section, depreciation and interest on any capital assets that cost five hundred dollars or more per item, including the following:
(i) Buildings;
(ii) Building improvements that are not approved as nonextensive renovations undersection 5124.17 of the Revised Code;
(iii) Equipment;
(iv) Extensive renovations;
(v) Transportation equipment.
(b) Amortization and interest on land improvements and leasehold improvements;
(c) Amortization of financing costs;
(d) Except as provided in division (Z) of this section, lease and rent of land, building, and equipment.
(2) The costs of capital assets of less than five hundred dollars per item may be considered costs of ownership in accordance with an ICF/IID provider's practice.
(1) "Date of licensure" means the following:
(a) In the case of an ICF/IID that was originally licensed as a nursing home under Chapter 3721. of the Revised Code, the date that it was originally so licensed, regardless that it was subsequently licensed as a residential facility undersection 5123.19 of the Revised Code;
(b) In the case of an ICF/IID that was originally licensed as a residential facility undersection 5123.19 of the Revised Code, the date it was originally so licensed;
(c) In the case of an ICF/IID that was not required by law to be licensed as a nursing home or residential facility when it was originally operated as a residential facility, the date it first was operated as a residential facility, regardless of the date the ICF/IID was first licensed as a nursing home or residential facility.
(2) If, after an ICF/IID's original date of licensure, more residential facility beds are added to the ICF/IID or all or part of the ICF/IID undergoes an extensive renovation, the ICF/IID has a different date of licensure for the additional beds or extensively renovated portion of the ICF/IID. This does not apply, however, to additional beds when both of the following apply:
(a) The additional beds are located in a part of the ICF/IID that was constructed at the same time as the continuing beds already located in that part of the ICF/IID;
(b) The part of the ICF/IID in which the additional beds are located was constructed as part of the ICF/IID at a time when the ICF/IID was not required by law to be licensed as a nursing home or residential facility.
(3) The definition of "date of licensure" in this section applies in determinations of ICFs/IID's medicaid payment rates but does not apply in determinations of ICFs/IID's franchise permit fees under sections 5168.60 to 5168.71 of the Revised Code.
(J) "Desk-reviewed" means that an ICF/IID's costs as reported on a cost report filed undersection 5124.10 or 5124.101 of the Revised Code have been subjected to a desk review undersection 5124.108 of the Revised Code and preliminarily determined to be allowable costs.
(K) "Developmental center" means a residential facility that is maintained and operated by the department of developmental disabilities.
(L) "Direct care costs" means all of the following costs incurred by an ICF/IID:
(1) Costs for registered nurses, licensed practical nurses, and nurse aides employed by the ICF/IID;
(2) Costs for direct care staff, administrative nursing staff, medical directors, respiratory therapists, physical therapists, physical therapy assistants, occupational therapists, occupational therapy assistants, speech therapists, audiologists, habilitation staff (including habilitation supervisors), qualified intellectual disability professionals, program directors, social services staff, activities staff, off-site day programming, psychologists, psychology assistants, social workers, counselors, and other persons holding degrees qualifying them to provide therapy;
(3) Costs of purchased nursing services;
(4) Costs of training and staff development, employee benefits, payroll taxes, and workers' compensation premiums or costs for self-insurance claims and related costs as specified in rules adopted under section 5124.03 of the Revised Code, for personnel listed in divisions (L)(1), (2), and (3) of this section;
(5) Costs of quality assurance;
(6) Costs of consulting and management fees related to direct care;
(7) Allocated direct care home office costs;
(8) Costs of other direct-care resources that are specified as direct care costs in rules adopted undersection 5124.03 of the Revised Code.
(M) "Downsized ICF/IID" means an ICF/IID that permanently reduced its medicaid-certified capacity pursuant to a plan approved by the department of developmental disabilities under section 5123.042 of the Revised Code.
(N) "Effective date of a change of operator" means the day the entering operator becomes the operator of the ICF/IID.
(O) "Effective date of a facility closure" means the last day that the last of the residents of the ICF/IID resides in the ICF/IID.
(P) "Effective date of an involuntary termination" means the date the department of medicaid terminates the operator's provider agreement for the ICF/IID or the last day that such a provider agreement is in effect when the department cancels or refuses to revalidate it.
(Q) "Effective date of a voluntary termination" means the day the ICF/IID ceases to accept medicaid recipients.
(R) "Entering operator" means the person or government entity that will become the operator of an ICF/IID when a change of operator occurs or following an involuntary termination.
(S) "Exiting operator" means any of the following:
(1) An operator that will cease to be the operator of an ICF/IID on the effective date of a change of operator;
(2) An operator that will cease to be the operator of an ICF/IID on the effective date of a facility closure;
(3) An operator of an ICF/IID that is undergoing or has undergone a voluntary termination;
(4) An operator of an ICF/IID that is undergoing or has undergone an involuntary termination.
(1) "Extensive renovation" means the following:
(a) An ICF/IID's betterment, improvement, or restoration to which both of the following apply:
(i) It was started before July 1, 1993;
(ii) It meets the definition of "extensive renovation" established in rules that were adopted by the director of job and family services and in effect on December 22, 1992.
(b) An ICF/IID's betterment, improvement, or restoration to which all of the following apply:
(i) It was started on or after July 1, 1993;
(ii) Except as provided in division (T)(2) of this section, it costs more than sixty-five per cent and not more than eighty-five per cent of the cost of constructing a new bed;
(iii) It extends the useful life of the assets for at least ten years.
(2) The department of developmental disabilities may treat a renovation that costs more than eighty-five per cent of the cost of constructing new beds as an extensive renovation if the department determines that the renovation is more prudent than construction of new beds.
(3) For the purpose of division (T)(1)(b)(ii) of this section, the cost of constructing a new bed shall be considered to be forty thousand dollars, adjusted for the estimated rate of inflation from January 1, 1993, to the end of the calendar year during which the extensive renovation is completed, using the consumer price index for shelter costs for all urban consumers for the north central region, as published by the United States bureau of labor statistics.
(1) Subject to divisions (U)(2) and (3) of this section, "facility closure" means either of the following:
(a) Discontinuance of the use of the building, or part of the building, that houses the facility as an ICF/IID that results in the relocation of all of the facility's residents;
(b) Conversion of the building, or part of the building, that houses an ICF/IID to a different use with any necessary license or other approval needed for that use being obtained and one or more of the facility's residents remaining in the facility to receive services under the new use.
(2) A facility closure occurs regardless of any of the following:
(a) The operator completely or partially replacing the ICF/IID by constructing a new ICF/IID or transferring the ICF/IID's license to another ICF/IID;
(b) The ICF/IID's residents relocating to another of the operator's ICFs/IID;
(c) Any action the department of health takes regarding the ICF/IID's medicaid certification that may result in the transfer of part of the ICF/IID's survey findings to another of the operator's ICFs/IID;
(d) Any action the department of developmental disabilities takes regarding the ICF/IID's license under section 5123.19 of the Revised Code.
(3) A facility closure does not occur if all of the ICF/IID's residents are relocated due to an emergency evacuation and one or more of the residents return to a medicaid-certified bed in the ICF/IID not later than thirty days after the evacuation occurs.
(V) "Fiscal year" means the fiscal year of this state, as specified insection 9.34 of the Revised Code.
(W) "Franchise permit fee" means the fee imposed by sections 5168.60 to 5168.71 of the Revised Code.
(X) "Home and community-based services" has the same meaning as in section 5123.01 of the Revised Code.
(Y) "ICF/IID services" has the same meaning as in 42 C.F.R. 440.150.
(1) "Indirect care costs" means all reasonable costs incurred by an ICF/IID other than capital costs, direct care costs, and other protected costs. "Indirect care costs" includes costs of habilitation supplies, pharmacy consultants, medical and habilitation records, program supplies, incontinence supplies, food, enterals, dietary supplies and personnel, laundry, housekeeping, security, administration, liability insurance, bookkeeping, purchasing department, human resources, communications, travel, dues, license fees, subscriptions, home office costs not otherwise allocated, legal services, accounting services, minor equipment, maintenance and repair expenses, help-wanted advertising, informational advertising, start-up costs, organizational expenses, other interest, property insurance, employee training and staff development, employee benefits, payroll taxes, and workers' compensation premiums or costs for self-insurance claims and related costs, as specified in rules adopted undersection 5124.03of the Revised Code, for personnel listed in this division. Notwithstanding division (H) of this section, "indirect care costs" also means the cost of equipment, including vehicles, acquired by operating lease executed before December 1, 1992, if the costs are reported as administrative and general costs on the ICF/IID's cost report for the cost reporting period ending December 31, 1992.
(2) For the purpose of division (Z)(1) of this section, an operating lease shall be construed in accordance with generally accepted accounting principles.
(AA) "Inpatient days" means both of the following:
(1) All days during which a resident, regardless of payment source, occupies a bed in an ICF/IID that is included in the ICF/IID's medicaid-certified capacity;
(2) All days for which payment is made undersection 5124.34 of the Revised Code.
(BB) "Intermediate care facility for individuals with disabilities" and "ICF/IID" mean an intermediate care facility for the mentally retarded as defined in the "Social Security Act," section 1905(d), 42 U.S.C. 1396d(d).
(CC) "Involuntary termination" means the department of medicaid's termination of, cancellation of, or refusal to revalidate the operator's provider agreement for the ICF/IID when such action is not taken at the operator's request.
(DD) "Maintenance and repair expenses" means, except as provided in division (TT)(2)(b) of this section, expenditures that are necessary and proper to maintain an asset in a normally efficient working condition and that do not extend the useful life of the asset two years or more. "Maintenance and repair expenses" includes the costs of ordinary repairs such as painting and wallpapering.
(EE) "Medicaid-certified capacity" means the number of an ICF/IID's beds that are certified for participation in medicaid as ICF/IID beds.
(FF) "Medicaid days" means both of the following:
(1) All days during which a resident who is a medicaid recipient eligible for ICF/IID services occupies a bed in an ICF/IID that is included in the ICF/IID's medicaid-certified capacity;
(2) All days for which payment is made under section 5124.34 of the Revised Code.
(1) "New ICF/IID" means an ICF/IID for which the provider obtains an initial provider agreement following the director of health's medicaid certification of the ICF/IID, including such an ICF/IID that replaces one or more ICFs/IID for which a provider previously held a provider agreement.
(2) "New ICF/IID" does not mean either of the following:
(a) An ICF/IID for which the entering operator seeks a provider agreement pursuant to section 5124.511 or 5124.512 or (pursuant to section 5124.515) section 5124.07 of the Revised Code;
(b) A downsized ICF/IID or partially converted ICF/IID.
(HH) "Nursing home" has the same meaning as in section 3721.01 of the Revised Code.
(II) "Operator" means the person or government entity responsible for the daily operating and management decisions for an ICF/IID.
(JJ) "Other protected costs" means costs incurred by an ICF/IID for medical supplies; real estate, franchise, and property taxes; natural gas, fuel oil, water, electricity, sewage, and refuse and hazardous medical waste collection; allocated other protected home office costs; and any additional costs defined as other protected costs in rules adopted under section 5124.03 of the Revised Code.
(1) "Owner" means any person or government entity that has at least five per cent ownership or interest, either directly, indirectly, or in any combination, in any of the following regarding an ICF/IID:
(a) The land on which the ICF/IID is located;
(b) The structure in which the ICF/IID is located;
(c) Any mortgage, contract for deed, or other obligation secured in whole or in part by the land or structure on or in which the ICF/IID is located;
(d) Any lease or sublease of the land or structure on or in which the ICF/IID is located.
(2) "Owner" does not mean a holder of a debenture or bond related to an ICF/IID and purchased at public issue or a regulated lender that has made a loan related to the ICF/IID unless the holder or lender operates the ICF/IID directly or through a subsidiary.
(LL) "Partially converted ICF/IID" means an ICF/IID that converted some, but not all, of its beds to providing home and community-based services under the individual options waiver pursuant to section 5124.60 or 5124.61 of the Revised Code.
(1) Except as provided in divisions (MM)(2) and (3) of this section, "per diem" means an ICF/IID's desk-reviewed, actual, allowable costs in a given cost center in a cost reporting period, divided by the facility's inpatient days for that cost reporting period.
(2) When determining capital costs for the purpose of section 5124.17 of the Revised Code, "per diem" means an ICF/IID's actual, allowable capital costs in a cost-reporting period divided by the greater of the facility's inpatient days for that period or the number of inpatient days the ICF/IID would have had during that period if its occupancy rate had been ninety-five per cent.
(3) When determining indirect care costs for the purpose of section 5124.21 of the Revised Code, "per diem" means an ICF/IID's actual, allowable indirect care costs in a cost-reporting period divided by the greater of the ICF/IID's inpatient days for that period or the number of inpatient days the ICF/IID would have had during that period if its occupancy rate had been eighty-five per cent.
(NN) "Provider" means an operator with a valid provider agreement.
(OO) "Provider agreement" means a provider agreement, as defined in section 5164.01 of the Revised Code, that is between the department of medicaid and the operator of an ICF/IID for the provision of ICF/IID services under the medicaid program.
(PP) "Purchased nursing services" means services that are provided in an ICF/IID by registered nurses, licensed practical nurses, or nurse aides who are not employees of the ICF/IID.
(QQ) "Reasonable" means that a cost is an actual cost that is appropriate and helpful to develop and maintain the operation of resident care facilities and activities, including normal standby costs, and that does not exceed what a prudent buyer pays for a given item or services. Reasonable costs may vary from provider to provider and from time to time for the same provider.
(RR) "Related party" means an individual or organization that, to a significant extent, has common ownership with, is associated or affiliated with, has control of, or is controlled by, a provider.
(1) An individual who is a relative of an owner is a related party.
(2) Common ownership exists when an individual or individuals possess significant ownership or equity in both the provider and the other organization. Significant ownership or equity exists when an individual or individuals possess five per cent ownership or equity in both the provider and a supplier. Significant ownership or equity is presumed to exist when an individual or individuals possess ten per cent ownership or equity in both the provider and another organization from which the provider purchases or leases real property.
(3) Control exists when an individual or organization has the power, directly or indirectly, to significantly influence or direct the actions or policies of an organization.
(4) An individual or organization that supplies goods or services to a provider shall not be considered a related party if all of the following conditions are met:
(a) The supplier is a separate bona fide organization.
(b) A substantial part of the supplier's business activity of the type carried on with the provider is transacted with others than the provider and there is an open, competitive market for the types of goods or services the supplier furnishes.
(c) The types of goods or services are commonly obtained by other ICFs/IID from outside organizations and are not a basic element of resident care ordinarily furnished directly to residents by the ICFs/IID.
(d) The charge to the provider is in line with the charge for the goods or services in the open market and no more than the charge made under comparable circumstances to others by the supplier.
(SS) "Relative of owner" means an individual who is related to an owner of an ICF/IID by one of the following relationships:
(1) Spouse;
(2) Natural parent, child, or sibling;
(3) Adopted parent, child, or sibling;
(4) Stepparent, stepchild, stepbrother, or stepsister;
(5) Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law;
(6) Grandparent or grandchild;
(7) Foster caregiver, foster child, foster brother, or foster sister.
(1) "Renovation" means the following:
(a) An ICF/IID's betterment, improvement, or restoration to which both of the following apply:
(i) It was started before July 1, 1993;
(ii) It meets the definition of "renovation" established in rules that were adopted by the director of job and family services and in effect on December 22, 1992.
(b) An ICF/IID's betterment, improvement, or restoration to which both of the following apply:
(i) It was started on or after July 1, 1993;
(ii) It betters, improves, or restores the ICF/IID beyond its current functional capacity through a structural change that costs at least five hundred dollars per bed.
(2) A renovation started on or after July 1, 1993, may include both of the following:
(a) A betterment, improvement, restoration, or replacement of assets that are affixed to a building and have a useful life of at least five years;
(b) Costs that otherwise would be considered maintenance and repair expenses if they are an integral part of the structural change that makes up the renovation project.
(3) "Renovation" does not mean construction of additional space for beds that will be added to an ICF/IID's licensed capacity or medicaid-certified capacity.
(UU) "Residential facility" has the same meaning as in section 5123.19 of the Revised Code.
(VV) "Sponsor" means an adult relative, friend, or guardian of an ICF/IID resident who has an interest or responsibility in the resident's welfare.
(WW) "Title XIX" means Title XIX of the "Social Security Act," 42 U.S.C. 1396, et seq.
(XX) "Title XVIII" means Title XVIII of the "Social Security Act," 42 U.S.C. 1395, et seq.
(YY) "Voluntary termination" means an operator's voluntary election to terminate the participation of an ICF/IID in the medicaid program but to continue to provide service of the type provided by a residential facility as defined in section 5123.19 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of medicaid shall enter into a contract with the department of developmental disabilities under section 5162.35 of the Revised Code that provides for the department of developmental disabilities to assume the powers and duties of the department of medicaid with regard to the medicaid program's coverage of ICF/IID services . The contract shall include a schedule for the assumption of the powers and duties. The contract may provide for the department of medicaid to perform one or more duties of the department of developmental disabilities under sections 5124.50 to 5124.53 of the Revised Code. Except as otherwise authorized by the United States secretary of health and human services, no provision of the contract may violate a federal law or regulation governing the medicaid program.
Renumbered from § 5111.226 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Added by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
To the extent authorized by rules authorized by section 5162.021 of the Revised Code, the director of developmental disabilities shall adopt rules in accordance with Chapter 119. of the Revised Code as necessary to implement this chapter.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The medicaid program shall cover ICF/IID services when all of the following apply:
(A) The ICF/IID services are provided to a medicaid recipient eligible for the services.
(B) The ICF/IID services are provided by an ICF/IID for which the provider has a valid provider agreement.
(C) Federal financial participation is available for the ICF/IID services.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Subject to section 5124.072 of the Revised Code, an ICF/IID operator is eligible to enter into a provider agreement for an ICF/IID if all of the following apply:
(1) The ICF/IID is certified by the director of health for participation in medicaid;
(2) The ICF/IID is licensed by the director of developmental disabilities as a residential facility;
(3) Subject to division (B) of this section, the operator and ICF/IID comply with all applicable state and federal statutes and rules.
(B) A state rule that requires an ICF/IID operator to have received approval of a plan for the proposed ICF/IID pursuant to section 5123.042 of the Revised Code as a condition of the operator being eligible to receive medicaid payments for ICF/IID services the ICF/IID provides does not apply if, under former section 5123.193 of the Revised Code as enacted by Am. Sub. H.B. 1 of the 128th general assembly or section 5123.197 of the Revised Code, a residential facility license was obtained or modified for the ICF/IID without obtaining approval of such a plan.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Except as provided in section 5124.072 of the Revised Code, the department of medicaid shall enter into a provider agreement with an ICF/IID operator who applies, and is eligible, for the provider agreement.
(B) A provider agreement shall require the department of developmental disabilities, pursuant to its agreement with the department of medicaid under section 5124.02 of the Revised Code, to make medicaid payments to the provider in accordance with this chapter for ICF/IID services the ICF/IID provides to its residents who are medicaid recipients eligible for ICF/IID services.
(C) A provider agreement shall require the provider to do all of the following:
(1) Maintain eligibility for the provider agreement as provided in section 5124.06 of the Revised Code;
(2) Keep records relating to a cost reporting period for the greater of seven years after the cost report is filed or, if the department of developmental disabilities issues an audit report in accordance with section 5124.109 of the Revised Code, six years after all appeal rights relating to the audit report are exhausted;
(3) File reports as the department of developmental disabilities requires;
(4) Open all records relating to the costs of the ICF/IID's services for inspection and audit by the department of developmental disabilities;
(5) Open its premises for inspection by the department of developmental disabilities, department of health, and any other state or local authority having authority to inspect;
(6) Supply to the department of developmental disabilities such information as it requires concerning the ICF/IID's services to residents who are, or are eligible to be, medicaid recipients;
(7) Comply with section 5124.08 of the Revised Code.
(D) A provider agreement may contain other provisions that are consistent with law and considered necessary by the department of medicaid or the department of developmental disabilities.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
An ICF/IID operator may enter into provider agreements for more than one ICF/IID.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of medicaid shall not revalidate an ICF/IID provider agreement if the provider fails to maintain eligibility for the provider agreement as provided in section 5124.06 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Every provider agreement with an ICF/IID provider shall do both of the following:
(1) Except as provided by division (B) of this section, include any part of the ICF/IID that meets federal and state standards for medicaid certification;
(2) Prohibit the provider from doing either of the following:
(a) Discriminating against a resident on the basis of race, color, sex, creed, or national origin;
(b) Subject to division (D) of this section, failing or refusing to do either of the following:
(i) Admit as a resident of the ICF/IID an individual because the individual is, or may (as a resident of the ICF/IID) become, a medicaid recipient if less than eighty per cent of the ICF/IID's residents are medicaid recipients;
(ii) Retain as a resident of the ICF/IID an individual because the individual is, or may (as a resident of the ICF/IID) become, a medicaid recipient.
(B) Unless otherwise required by federal law, an ICF/IID bed is not required to be included in a provider agreement if the bed is designated for respite care under a medicaid waiver component operated pursuant to a waiver sought under section 5166.20 of the Revised Code.
(C) For the purpose of division (A)(2)(b)(ii) of this section, a medicaid recipient who is a resident of an ICF/IID shall be considered a resident of the ICF/IID during any hospital stays totaling less than twenty-five days during any twelve-month period. A medicaid recipient identified by the department of developmental disabilities or its designee as requiring the level of care of an ICF/IID shall not be subject to a maximum period of absences during which the recipient is considered to be an ICF/IID resident if prior authorization of the department for visits with relatives and friends and participation in therapeutic programs is obtained in accordance with rules adopted under section 5124.03 of the Revised Code.
(D) Nothing in this section shall bar a provider from doing any of the following:
(1) If the provider is a religious organization operating a religious or denominational ICF/IID, giving preference to persons of the same religion or denomination;
(2) Giving preference to persons with whom the provider has contracted to provide continuing care;
(3) Retaining residents who have resided in the provider's ICF/IID for not less than one year as private pay residents and who subsequently become medicaid recipients but refusing to admit as a resident an individual who is, or may (as a resident of the ICF/IID) become, a medicaid recipient, if all of the following apply:
(a) The provider does not refuse to retain a resident who has resided in the provider's ICF/IID for not less than one year as a private pay resident because the resident becomes a medicaid recipient, except as necessary to comply with division (D)(3)(b) of this section.
(b) The number of medicaid recipients retained under division (D)(3) of this section does not at any time exceed ten per cent of all the ICF/IID's residents.
(c) On July 1, 1980, all the ICF/IID's residents were private pay residents.
(E) No provider shall violate the provider agreement obligations imposed by this section.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
An ICF/IID resident has a cause of action against the provider of the ICF/IID for breach of the provider agreement obligations or other duties imposed by section 5124.08 of the Revised Code. The action may be commenced by the resident, or on the resident's behalf by the resident's sponsor, by the filing of a civil action in the court of common pleas of the county in which the ICF/IID is located or in the court of common pleas of Franklin county.
If a court of common pleas finds that a provider has breached a provider agreement obligation or other duty imposed by section 5124.08 of the Revised Code, the court may do one or more of the following:
(A) Enjoin the provider from engaging in the practice;
(B) Order such affirmative relief as may be necessary;
(C) Award to a resident and a sponsor that brings the action on behalf of a resident actual damages, costs, and reasonable attorney's fees.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Except as provided in division (D) of this section and division (E)(2) of section 5124.101 of the Revised Code, each ICF/IID provider shall file with the department of developmental disabilities an annual cost report for each of the provider's ICFs/IID for which the provider has a valid provider agreement. The cost report for a year shall cover the calendar year or portion of the calendar year during which the ICF/IID participated in the medicaid program. Except as provided in division (E) of this section, the cost report is due not later than ninety days after the end of the calendar year, or portion of the calendar year, that the cost report covers.
(1) If an ICF/IID undergoes a change of provider that the department determines, in accordance with rules adopted under section 5124.03 of the Revised Code, is not an arms length transaction, the new provider shall file the ICF/IID's cost report in accordance with division (A) of this section and the cost report shall cover the portion of the calendar year during which the new provider operated the ICF/IID and the portion of the calendar year during which the previous provider operated the ICF/IID.
(2) If an ICF/IID undergoes a change of provider that the department determines, in accordance with rules adopted under section 5124.03 of the Revised Code, is an arms length transaction, the new provider shall file with the department a cost report for the ICF/IID not later than, except as provided in division (E) of this section, ninety days after the end of the ICF/IID's first three full calendar months of operation under the new provider. The cost report shall cover the period that begins with the ICF/IID's first day of operation under the new provider and ends on the first day of the month immediately following the first three full months of operation under the new provider.
(C) If the medicaid payment rate for a new ICF/IID was most recently determined in accordance with section 5124.151 of the Revised Code, the provider shall file with the department a cost report for the new ICF/IID not later than, except as provided in division (E) of this section, ninety days after the end of the new ICF/IID's first three full calendar months of operation. The cost report shall cover the period that begins with the ICF/IID's first day of operation and ends on the first day of the month immediately following the first three full months of operation.
(D) An ICF/IID provider is not required to file a cost report for an ICF/IID for a calendar year in accordance with division (A) of this section if the provider files a cost report for the ICF/IID under division (B)(2) or (C) of this section and that cost report covers a period that begins after the first day of October of that calendar year. The provider shall file a cost report for the ICF/IID in accordance with division (A) of this section for the immediately following calendar year.
(E) The department may grant to a provider a fourteen-day extension to file a cost report under this section or section 5124.101 of the Revised Code if the provider provides the department a written request for the extension and the department determines that there is good cause for the extension.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) The provider of an ICF/IID that becomes a downsized ICF/IID or partially converted ICF/IID on or after July 1, 2013, or becomes a new ICF/IID on or after that date, may file with the department of developmental disabilities a cost report covering the period specified in division (B) of this section if the following applies to the ICF/IID:
(1) In the case of an ICF/IID that becomes a downsized ICF/IID or partially converted ICF/IID, the ICF/IID has either of the following on the day it becomes a downsized ICF/IID or partially converted ICF/IID:
(a) A medicaid-certified capacity that is at least ten per cent less than its medicaid-certified capacity on the day immediately preceding the day it becomes a downsized ICF/IID or partially converted ICF/IID;
(b) At least five fewer beds certified as ICF/IID beds than it has on the day immediately preceding the day it becomes a downsized ICF/IID or partially converted ICF/IID.
(2) In the case of a new ICF/IID, the ICF/IID's beds are from a downsized ICF/IID and the downsized ICF/IID has either of the following on the day it becomes a downsized ICF/IID:
(a) A medicaid-certified capacity that is at least ten per cent less than its medicaid-certified capacity on the day immediately preceding the day it becomes a downsized ICF/IID;
(b) At least five fewer beds certified as ICF/IID beds than it has on the day immediately preceding the day it becomes a downsized ICF/IID.
(B) A cost report filed under division (A) of this section shall cover the period that begins and ends as follows:
(1) In the case of an ICF/IID that becomes a downsized ICF/IID or partially converted ICF/IID:
(a) The period begins with the day that the ICF/IID becomes a downsized ICF/IID or partially converted ICF/IID.
(b) The period ends on the last day of the last month of the first three full months of operation as a downsized ICF/IID or partially converted ICF/IID.
(2) In the case of a new ICF/IID:
(a) The period begins with the day that the provider agreement for the ICF/IID takes effect.
(b) The period ends on the last day of the last month of the first three full months that the provider agreement is in effect.
(C) The department shall refuse to accept a cost report filed under division (A) of this section if either of the following apply:
(1) Except as provided in division (E) of section 5124.10 of the Revised Code, the provider fails to file the cost report with the department not later than ninety days after the last day of the period the cost report covers;
(2) The cost report is incomplete or inadequate.
(D) If the department accepts a cost report filed under division (A) of this section, the department shall use that cost report, rather than the cost report that otherwise would be used pursuant to section 5124.17, 5124.19, 5124.21, or 5124.23 of the Revised Code, to determine the ICF/IID's medicaid payment rate in accordance with this chapter for ICF/IID services the ICF/IID provides during the period that begins and ends as follows:
(1) The period begins on the following:
(a) In the case of an ICF/IID that becomes a downsized ICF/IID or partially converted ICF/IID:
(i) The day that the ICF/IID becomes a downsized ICF/IID or partially converted ICF/IID if that day is the first day of a month;
(ii) The first day of the month immediately following the month that the ICF/IID becomes a downsized ICF/IID or partially converted ICF/IID if division (D)(1)(a)(i) of this section does not apply.
(b) In the case of a new ICF/IID, the day that the ICF/IID's provider agreement takes effect.
(2) The period ends on the last day of the fiscal year that immediately precedes the fiscal year for which the ICF/IID begins to be paid a rate determined using a cost report that division (E) of this section requires be filed in accordance with division (A) of section 5124.10 of the Revised Code.
(1) If the department accepts a cost report filed under division (A) of this section for an ICF/IID that becomes a downsized ICF/IID or partially converted ICF/IID on or before the first day of October of a calendar year, or for a new ICF/IID that has a provider agreement that takes effect on or before that date, the provider also shall file a cost report for the ICF/IID in accordance with division (A) of section 5124.10 of the Revised Code for the portion of that calendar year that the ICF/IID operated as a downsized ICF/IID or partially converted ICF/IID or, in the case of a new ICF/IID, for the portion that the provider agreement was in effect.
(2) If the department accepts a cost report filed under division (A) of this section for an ICF/IID that becomes a downsized ICF/IID or partially converted ICF/IID after the first day of October of a calendar year, or for a new ICF/IID that has a provider agreement that takes effect on or after that date, the provider is not required to file a cost report for that calendar year in accordance with division (A) of section 5124.10 of the Revised Code. The provider shall file a cost report for the ICF/IID in accordance with division (A) of section 5124.10 of the Revised Code for the immediately following calendar year.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
No ICF/IID provider shall report fines paid under section 5124.99 of the Revised Code in a cost report filed under section 5124.10, 5124.101, or 5124.522 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Cost reports shall be completed using the form prescribed under section 5124.104 of the Revised Code and in accordance with the guidelines established under that section.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities shall do all of the following:
(A) Prescribe the form to be used for completing a cost report and a uniform chart of accounts for the purpose of reporting costs on the form;
(B) Distribute a paper copy of the form, or computer software for electronic submission of the form, to each provider at least sixty days before the date the cost report is due;
(C) Establish guidelines for completing the form.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities shall develop an addendum to the cost report form that an ICF/IID provider may use to set forth costs that the provider believes the department may dispute. The department may consider such costs in determining an ICF/IID's medicaid payment rate. If the department does not consider such costs in determining an ICF/IID's medicaid payment rate, the provider may seek reconsideration of the determination in accordance with section 5124.38 of the Revised Code. If the department subsequently includes such costs in an ICF/IID's medicaid payment rate, the department shall pay the provider interest at a reasonable rate established in rules adopted under section 5124.03 of the Revised Code for the period that the rate excluded the costs.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
If an ICF/IID provider required by section 5124.10 of the Revised Code to file a cost report for the ICF/IID fails to file the cost report by the date it is due or the date, if any, to which the due date is extended pursuant to division (E) of that section, or files an incomplete or inadequate report for the ICF/IID under that section, the department of developmental disabilities shall provide immediate written notice to the provider that the provider agreement for the ICF/IID will be terminated in thirty days unless the provider submits a complete and adequate cost report for the ICF/IID within thirty days. During the thirty-day termination period or any additional time allowed for an appeal of the proposed termination of a provider agreement, the provider shall be paid the ICF/IID's then current per medicaid day payment rate, minus the dollar amount by which ICFs/IID's per medicaid day payment rates are reduced during fiscal year 2013 in accordance with division (A)(2) of section 5111.26 of the Revised Code (renumbered as section 5165.10 of the Revised Code by H.B. 59 of the 130th general assembly) as that section existed on the day immediately preceding the effective date of this section. On the first day of each July, the department shall adjust the amount of the reduction in effect during the previous twelve months to reflect the rate of inflation during the preceding twelve months, as shown in the consumer price index for all items for all urban consumers for the midwest region, published by the United States bureau of labor statistics.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Except as provided in division (B) of this section and not later than three years after an ICF/IID provider files a cost report with the department of developmental disabilities under section 5124.10 or 5124.101 of the Revised Code, the provider may amend the cost report if the provider discovers a material error in the cost report or additional information to be included in the cost report. The department shall review the amended cost report for accuracy and notify the provider of its determination.
(B) An ICF/IID provider may not amend a cost report if the department has notified the provider that an audit of the cost report or a cost report of the provider for a subsequent cost reporting period is to be conducted under section 5124.109 of the Revised Code. The provider may, however, provide the department information that affects the costs included in the cost report. Such information may not be provided after the adjudication of the final settlement of the cost report.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities shall conduct a desk review of all cost reports it receives under sections 5124.10, 5124.101, and 5124.522 of the Revised Code. Based on the desk review, the department shall make a preliminary determination of whether the reported costs are allowable costs. The department shall notify each ICF/IID provider of whether any of the reported costs are preliminarily determined not to be allowable costs, the medicaid payment rate determined under this chapter as a result of the determination regarding allowable costs, and the reasons for the determination and resulting rate. The department shall allow the provider to verify the calculation and submit additional information.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) The department of developmental disabilities may conduct an audit, as defined in rules adopted under section 5124.03 of the Revised Code, of any cost report filed under section 5124.10, 5124.101, or 5124.522 of the Revised Code. The decision whether to conduct an audit and the scope of the audit, which may be a desk or field audit, may be determined based on prior performance of the provider, a risk analysis, or other evidence that gives the department reason to believe that the provider has reported costs improperly. A desk or field audit may be performed annually, but is required whenever a provider does not pass the risk analysis tolerance factors.
(B) Audits shall be conducted by auditors under contract with the department, auditors working for firms under contract with the department, or auditors employed by the department.
The department may establish a contract for the auditing of ICFs/IID by outside firms. Each contract entered into by bidding shall be effective for one to two years.
(C) The department shall notify a provider of the findings of an audit of a cost report by issuing an audit report. The department shall issue the audit report not later than three years after the earlier of the following:
(1) The date the cost report is filed;
(2) The date a desk or field audit of the cost report or a cost report for a subsequent cost reporting period is completed.
(D) The department shall prepare a written summary of any audit disallowance that is made after the effective date of the rate that is based on the cost. Where the provider is pursuing judicial or administrative remedies in good faith regarding the disallowance, the department shall not withhold from the provider's current payments any amounts the department claims to be due from the provider pursuant to section 5124.41 of the Revised Code.
(1) The department shall establish an audit manual and program for field audits conducted under this section. Each auditor conducting a field audit under this section shall follow the audit manual and program, regardless of whether the auditor is under contract with the department, works for a firm under contract with the department, or is employed by the department. The manual and program shall do both of the following:
(a) Require each field audit to be conducted by an auditor to whom all of the following apply:
(i) During the period of the auditor's contract, firm's contract, or auditor's employment with the department, the auditor or firm does not have and is not committed to acquire any direct or indirect financial interest in the ownership, financing, or operation of ICFs/IID in this state.
(ii) The auditor does not audit any provider that has been a client of the auditor or the auditor's firm.
(iii) The auditor is otherwise independent as determined by the standards of independence included in the government auditing standards produced by the United States government accountability office.
(b) Require each auditor conducting a field audit to do all of the following:
(i) Comply with applicable rules prescribed pursuant to Title XIX;
(ii) Consider generally accepted auditing standards prescribed by the American institute of certified public accountants;
(iii) Include a written summary as to whether the costs included in the cost report examined during the audit are allowable and are presented in accordance with state and federal laws and regulations, and whether, in all material respects, allowable costs are documented, reasonable, and related to patient care;
(iv) Complete the audit within the time period specified by the department;
(v) Provide to the provider complete written interpretations that explain in detail the application of all relevant contract provisions, regulations, auditing standards, rate formulae, and departmental policies, with explanations and examples, that are sufficient to permit the provider to calculate with reasonable certainty those costs that are allowable and the rate to which the provider's ICF/IID is entitled.
(2) For the purpose of division (E)(1)(a)(i) of this section, employment of a member of an auditor's family by an ICF/IID that the auditor does not audit does not constitute a direct or indirect financial interest in the ownership, financing, or operation of the ICF/IID.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Except as otherwise provided by sections 5124.151 to 5124.154 of the Revised Code and division (B) of this section, the total per medicaid day payment rate that the department of developmental disabilities shall pay to an ICF/IID provider for ICF/IID services the provider's ICF/IID provides during a fiscal year shall equal the sum of all of the following:
(1) The per medicaid day payment rate for capital costs determined for the ICF/IID under section 5124.17 of the Revised Code;
(2) The per medicaid day payment rate for direct care costs determined for the ICF/IID under section 5124.19 of the Revised Code;
(3) The per medicaid day payment rate for indirect care costs determined for the ICF/IID under section 5124.21 of the Revised Code;
(4) The per medicaid day payment rate for other protected costs determined for the ICF/IID under section 5124.23 of the Revised Code
.
(B) The department shall adjust the total rate otherwise determined under division (A) of this section as directed by the general assembly through the enactment of law governing medicaid payments to ICF/IID providers .
(C) In addition to paying an ICF/IID provider the total rate determined for the provider's ICF/IID under divisions (A) and (B) of this section for a fiscal year, the department, in accordance with section 5124.25 of the Revised Code, may pay the provider a rate add-on for pediatric ventilator-dependent outlier ICF/IID services if the rate add-on is to be paid under that section and the department approves the provider's application for the rate add-on. The rate add-on is not to be part of the ICF/IID's total rate.
Renumbered from § 5111.224 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Added by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
(A) The total per medicaid day payment rate determined under section 5124.15 of the Revised Code shall not be the initial rate for ICF/IID services provided by a new ICF/IID. Instead, the initial total per medicaid day payment rate for ICF/IID services provided by a new ICF/IID shall be determined in the following manner:
(1) The initial rate for capital costs shall be determined under section 5124.17 of the Revised Code using the greater of the new ICF/IID's actual inpatient days or an imputed occupancy rate of eighty per cent.
(2) The initial rate for direct care costs shall be determined as follows:
(a) If there are no cost or resident assessment data for the new ICF/IID as necessary to determine a rate under section 5124.19 of the Revised Code, the rate shall be determined as follows:
(i) Determine the median cost per case-mix unit under division (B) of section 5124.19 of the Revised Code for the new ICF/IID's peer group for the calendar year immediately preceding the fiscal year in which the rate will be paid ;
(ii) Multiply the amount determined under division (A)(2)(a)(i) of this section by the median annual average case-mix score for the new ICF/IID's peer group for that period ;
(iii) Adjust the product determined under division (A)(2)(a)(ii) of this section by the rate of inflation estimated under division (D) of section 5124.19 of the Revised Code.
(b) If the new ICF/IID is a replacement ICF/IID and the ICF/IID or ICFs/IID that are being replaced are in operation immediately before the new ICF/IID opens, the rate shall be the same as the rate for the replaced ICF/IID or ICFs/IID, proportionate to the number of ICF/IID beds in each replaced ICF/IID.
(c) If the new ICF/IID is a replacement ICF/IID and the ICF/IID or ICFs/IID that are being replaced are not in operation immediately before the new ICF/IID opens, the rate shall be determined under division (A) (2)(a) of this section.
(3) The initial rate for indirect care costs shall be the maximum rate for the new ICF/IID's peer group as determined for the fiscal year in accordance with division (C) of section 5124.21 of the Revised Code.
(4) The initial rate for other protected costs shall be one hundred fifteen per cent of the median rate for ICFs/IID determined for the fiscal year under section 5124.23 of the Revised Code.
(B) (1) Except as provided in division (B)(2) of this section, the department shall adjust a new ICF/IID's initial total per medicaid day payment rate determined under this section
effective the first day of July, to reflect new rate determinations for all ICFs/IID under
this chapter.
(2) If the department accepts, under division (A) of section 5124.101 of the Revised Code, a cost report filed by the provider of a new ICF/IID, the department shall adjust the ICF/IID's initial total per medicaid day payment rate in accordance with divisions (D) and (E) of that section rather than division (B)(1) of this section.
Renumbered from § 5111.255 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Effective Date: 07-01-2000; 07-01-2005
(A) The total per medicaid day payment rate determined under section 5124.15 of the Revised Code shall not be paid for ICF/IID services provided by an ICF/IID, or discrete unit of an ICF/IID, designated by the department of developmental disabilities as an outlier ICF/IID or unit. Instead, the provider of a designated outlier ICF/IID or unit shall be paid each fiscal year a total per medicaid day payment rate that the department shall prospectively determine in accordance with a methodology established in rules authorized by this section.
(B) The department may designate an ICF/IID, or discrete unit of an ICF/IID, as an outlier ICF/IID or unit if the ICF/IID or unit serves residents who have either of the following:
(1) Diagnoses or special care needs that require direct care resources that are not measured adequately by the resident assessment instrument specified in rules authorized by section 5124.191 of the Revised Code;
(2) Diagnoses or special care needs that are specified in rules authorized by this section as otherwise qualifying for consideration under this section.
(C) Notwithstanding any other provision of this chapter, the costs incurred by a designated outlier ICF/IID or unit shall not be considered in establishing medicaid payment rates for other ICFs/IID or units.
(D) The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code as necessary to implement this section.
(a) The rules shall do both of the following:
(i) Specify the criteria and procedures the department will apply when designating an ICF/IID, or discrete unit of an ICF/IID, as an outlier ICF/IID or unit;
(ii) Establish a methodology for prospectively determining the total per medicaid day payment rate that will be paid each fiscal year for ICF/IID services provided by a designated outlier ICF/IID or unit.
(b) The rules adopted under division (D)(1)(a)(i) of this section regarding the criteria for designating outlier ICFs/IID and units shall do both of the following:
(i) Provide for consideration of whether all of the allowable costs of an ICF/IID, or discrete unit of an ICF/IID, would be paid by the rate determined under section 5124.15 of the Revised Code;
(ii) Specify the minimum number of ICF/IID beds that an ICF/IID, or discrete unit of an ICF/IID, must have to be designated an outlier ICF/IID or unit.
(c) The rules authorized by division (D)(1)(a)(i) of this section regarding the criteria for designating outlier ICFs/IID and units shall not limit the designation to ICFs/IID, or discrete units of ICFs/IID, located in large cities.
(d) The rules authorized by division (D)(1)(a)(ii) of this section regarding the methodology for prospectively determining the rates of designated outlier ICFs/IID and units shall provide for the methodology to consider the historical costs of providing ICF/IID services to the residents of designated outlier ICFs/IID and units.
(a) The rules may do both of the following:
(i) Include for designation as an outlier ICF/IID or unit, an ICF/IID, or discrete unit of an ICF/IID, that serves residents who have complex medical conditions or severe behavioral problems;
(ii) Require that a designated outlier ICF/IID or unit receive authorization from the department before admitting or retaining a resident.
(b) If the director adopts rules authorized by division (D)(2)(a)(ii) of this section regarding the authorization of a designated outlier ICF/IID or unit to admit or retain a resident, the rules shall specify the criteria and procedures the department will apply when granting the authorization.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) To the extent, if any, provided for in rules authorized by this section, the total per medicaid day payment rate determined under section 5124.15 of the Revised Code shall not be paid for ICF/IID services that an ICF/IID not designated as an outlier ICF/IID or unit provides to a resident who meets the criteria for admission to a designated outlier ICF/IID or unit, as specified in rules authorized by section 5124.152 of the Revised Code. Instead, the provider of an ICF/IID providing ICF/IID services to such a resident shall be paid each fiscal year a total per medicaid day payment rate that the department shall prospectively determine in accordance with a methodology established in rules authorized by this section.
(B) The director of developmental disabilities may adopt rules under section 5124.03 of the Revised Code to implement this section. The rules may require that an ICF/IID receive authorization from the department before admitting or retaining a resident who meets the criteria for admission to a designated outlier ICF/IID or unit. If the director adopts such rules, the rules shall specify the criteria and procedures the department will apply when granting the authorization.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities is not required to pay the total per medicaid day payment rates determined under section 5124.15 of the Revised Code for ICF/IID services provided by developmental centers. Instead, the department may determine the medicaid payment rates for developmental centers according to the reasonable cost principles of Title XVIII.
Renumbered from § 5111.291 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Amended by 128th General Assemblych.28, SB 79, §1, eff. 10/6/2009.
Effective Date: 07-01-2000; 07-01-2005
(A) For each fiscal year, the department of developmental disabilities shall determine each ICF/IID's per medicaid day payment rate for reasonable capital costs. Except as otherwise provided in this chapter, an ICF/IID's rate shall be determined prospectively and based on the ICF/IID's capital costs for the calendar year preceding the fiscal year in which the rate will be paid. Subject to section 5124.28, an ICF/IID's rate shall equal the sum of the following:
(1) The ICF/IID's desk-reviewed, actual, allowable, per diem costs of ownership for the immediately preceding cost reporting period, limited as provided in divisions (B) and (C) of this section;
The ICF/IID's per medicaid day payment for the ICF/IID's per diem capitalized costs of nonextensive renovations determined under division (D)(1) of this section if the ICF/IID qualifies for a payment for such costs as specified in division (D)(2) of this section;
(3) The ICF/IID's per medicaid day efficiency incentive determined under division (E) of this section;
(4) Until fiscal year 2015, the ICF/IID's return on net equity determined under division (F) of this section.
(B) The costs of ownership per diem payment rates for ICFs/IID with more than eight beds shall not exceed the following limits:
(1) For ICFs/IID with dates of licensure prior to January 1, l958, not exceeding two dollars and fifty cents ;
(2) For ICFs/IID with dates of licensure after December 31, l957, but prior to January 1, l968, not exceeding:
(a) Three dollars and fifty cents if the cost of construction was three thousand five hundred dollars or more per bed;
(b) Two dollars and fifty cents if the cost of construction was less than three thousand five hundred dollars per bed.
(3) For ICFs/IID with dates of licensure after December 31, l967, but prior to January 1, l976, not exceeding:
(a) Four dollars and fifty cents if the cost of construction was five thousand one hundred fifty dollars or more per bed;
(b) Three dollars and fifty cents if the cost of construction was less than five thousand one hundred fifty dollars per bed, but exceeds three thousand five hundred dollars per bed;
(c) Two dollars and fifty cents if the cost of construction was three thousand five hundred dollars or less per bed.
(4) For ICFs/IID with dates of licensure after December 31, l975, but prior to January 1, l979, not exceeding:
(a) Five dollars and fifty cents if the cost of construction was six thousand eight hundred dollars or more per bed;
(b) Four dollars and fifty cents if the cost of construction was less than six thousand eight hundred dollars per bed but exceeds five thousand one hundred fifty dollars per bed;
(c) Three dollars and fifty cents if the cost of construction was five thousand one hundred fifty dollars or less per bed, but exceeds three thousand five hundred dollars per bed;
(d) Two dollars and fifty cents if the cost of construction was three thousand five hundred dollars or less per bed.
(5) For ICFs/IID with dates of licensure after December 31, l978, but prior to January 1, l980, not exceeding:
(a) Six dollars if the cost of construction was seven thousand six hundred twenty-five dollars or more per bed;
(b) Five dollars and fifty cents if the cost of construction was less than seven thousand six hundred twenty-five dollars per bed but exceeds six thousand eight hundred dollars per bed;
(c) Four dollars and fifty cents if the cost of construction was six thousand eight hundred dollars or less per bed but exceeds five thousand one hundred fifty dollars per bed;
(d) Three dollars and fifty cents if the cost of construction was five thousand one hundred fifty dollars or less but exceeds three thousand five hundred dollars per bed;
(e) Two dollars and fifty cents if the cost of construction was three thousand five hundred dollars or less per bed.
(6) For ICFs/IID with dates of licensure after December 31, 1979, but prior to January 1, 1981, not exceeding:
(a) Twelve dollars if the beds were originally licensed as residential facility beds by the department of developmental disabilities;
(b) Six dollars if the beds were originally licensed as nursing home beds by the department of health.
(7) For ICFs/IID with dates of licensure after December 31, 1980, but prior to January 1, 1982, not exceeding:
(a) Twelve dollars if the beds were originally licensed as residential facility beds by the department of developmental disabilities;
(b) Six dollars and forty-five cents if the beds were originally licensed as nursing home beds by the department of health.
(8) For ICFs/IID with dates of licensure after December 31, 1981, but prior to January 1, 1983, not exceeding:
(a) Twelve dollars if the beds were originally licensed as residential facility beds by the department of developmental disabilities;
(b) Six dollars and seventy-nine cents if the beds were originally licensed as nursing home beds by the department of health.
(9) For ICFs/IID with dates of licensure after December 31, 1982, but prior to January 1, 1984, not exceeding:
(a) Twelve dollars if the beds were originally licensed as residential facility beds by the department of developmental disabilities;
(b) Seven dollars and nine cents if the beds were originally licensed as nursing home beds by the department of health.
(10) For ICFs/IID with dates of licensure after December 31, 1983, but prior to January 1, 1985, not exceeding:
(a) Twelve dollars and twenty-four cents if the beds were originally licensed as residential facility beds by the department of developmental disabilities;
(b) Seven dollars and twenty-three cents if the beds were originally licensed as nursing home beds by the department of health.
(11) For ICFs/IID with dates of licensure after December 31, 1984, but prior to January 1, 1986, not exceeding:
(a) Twelve dollars and fifty-three cents if the beds were originally licensed as residential facility beds by the department of developmental disabilities;
(b) Seven dollars and forty cents if the beds were originally licensed as nursing home beds by the department of health.
(12) For ICFs/IID with dates of licensure after December 31, 1985, but prior to January 1, 1987, not exceeding:
(a) Twelve dollars and seventy cents if the beds were originally licensed as residential facility beds by the department of developmental disabilities;
(b) Seven dollars and fifty cents if the beds were originally licensed as nursing home beds by the department of health.
(13) For ICFs/IID with dates of licensure after December 31, 1986, but prior to January 1, 1988, not exceeding:
(a) Twelve dollars and ninety-nine cents if the beds were originally licensed as residential facility beds by the department of developmental disabilities;
(b) Seven dollars and sixty-seven cents if the beds were originally licensed as nursing home beds by the department of health.
(14) For ICFs/IID with dates of licensure after December 31, 1987, but prior to January 1, 1989, not exceeding thirteen dollars and twenty-six cents ;
(15) For ICFs/IID with dates of licensure after December 31, 1988, but prior to January 1, 1990, not exceeding thirteen dollars and forty-six cents ;
(16) For ICFs/IID with dates of licensure after December 31, 1989, but prior to January 1, 1991, not exceeding thirteen dollars and sixty cents ;
(17) For ICFs/IID with dates of licensure after December 31, 1990, but prior to January 1, 1992, not exceeding thirteen dollars and forty-nine cents ;
(18) For ICFs/IID with dates of licensure after December 31, 1991, but prior to January 1, 1993, not exceeding thirteen dollars and sixty-seven cents ;
(19) For ICFs/IID with dates of licensure after December 31, 1992, not exceeding fourteen dollars and twenty-eight cents .
(1) The costs of ownership per diem payment rate for an ICF/IID with eight or fewer beds shall not exceed the following limits:
(a) Eighteen dollars and thirty cents as adjusted for inflation pursuant to division (C)(2) of this section if any of the following apply to the ICF/IID:
(i) The ICF/IID has a date of licensure, or was granted project authorization by the department of developmental disabilities, before July 1, 1993.
(ii) The ICF/IID has a date of licensure, or was granted project authorization by the department, on or after July 1, 1993, and the provider demonstrates that the provider made substantial commitments of funds for the ICF/IID before that date.
(iii) The ICF/IID has a date of licensure, or was granted project authorization by the department, on or after July 1, 1993, the provider made no substantial commitment of funds for the ICF/IID before that date, and the department of job and family services or department of developmental disabilities gave prior approval for the ICF/IID's construction.
(b) If division (C)(1)(a) of this section does not apply to the ICF/IID, the amount that would apply to the ICF/IID under division (B) of this section if it had more than eight beds.
(2) The eighteen-dollar and thirty-cent payment rate specified in division (C)(1)(a) of this section shall be increased as follows:
(a) For the period beginning June 30, 1990, and ending July 1, 1993, by the change in the "Dodge building cost indexes, northeastern and north central states," published by Marshall and Swift;
(b) For each fiscal year thereafter, in accordance with division (G) of this section.
(1) Beginning January 1, 1981, regardless of the original date of licensure, the payment rate for the per diem capitalized costs of nonextensive renovations made after January 1, l981, to a qualifying ICF/IID, shall not exceed six dollars per medicaid day using 1980 as the base year and adjusting the amount annually until June 30, 1993, for fluctuations in construction costs calculated by the department using the "Dodge building cost indexes, northeastern and north central states," published by Marshall and Swift. The payment rate shall be further adjusted in accordance with division (G) of this section. The payment provided for in this division is the only payment that shall be made for an ICF/IID's capitalized costs of nonextensive renovations. Costs of nonextensive renovations shall not be included in costs of ownership and shall not affect the date of licensure for purposes of division (B) or (C) of this section. This division applies to nonextensive renovations regardless of whether they are made by an owner or a lessee. If the tenancy of a lessee that has made nonextensive renovations ends before the depreciation expense for the costs of nonextensive renovations has been fully reported, the former lessee shall not report the undepreciated balance as an expense.
(2) An ICF/IID qualifies for a payment for costs of nonextensive renovations if all of the following apply:
(a) Either of the following applies:
(i) The ICF/IID has more than eight beds and either the department approved the nonextensive renovation before July 1, 2013, or the nonextensive renovation is part of a project that results in the ICF/IID becoming a downsized ICF/IID or partially converted ICF/IID.
(ii) The ICF/IID has eight or fewer beds.
(b) At least five years have elapsed since the ICF/IID's date of licensure or date of an extensive renovation of the portion of the ICF/IID that is proposed to be nonextensively renovated, unless the nonextensive renovation is necessary to meet the requirements of federal, state, or local statutes, ordinances, rules, or policies.
(c) The provider of the ICF/IID does both of the following:
(i) Submits to the department a plan that describes in detail the changes in capital assets to be accomplished by means of the nonextensive renovation and the timetable for completing the project , which shall be not more than eighteen months after the nonextensive renovation begins;
(ii) Obtains prior approval from the department for the nonextensive renovation.
(3) The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code that specify criteria and procedures for prior approval of nonextensive renovation and extensive renovation projects. No provider shall separate a project with the intent to evade the characterization of the project as a nonextensive renovation or as an extensive renovation. No provider shall increase the scope of a project after it is approved by the department unless the increase in scope is approved by the department.
(1) Subject to division (E)(2) of this section, an ICF/IID's per medicaid day efficiency incentive payment rate shall equal the following percentage of the difference between the ICF/IID's desk-reviewed, actual, allowable per diem costs of ownership and the applicable limit on costs of ownership payment rates established by division (B) of this section:
(a) In the case of an ICF/IID with more than eight beds, the following percentage:
(i) Fifty per cent for fiscal year 2014;
(ii) Fifty per cent for fiscal year 2015 and each fiscal year thereafter if the provider of the ICF/IID obtains the department's approval to become a downsized ICF/IID and the approval is conditioned on the downsizing being completed not later than July 1, 2018;
(iii) Twenty-five per cent;
(b) In the case of an ICF/IID with eight or fewer beds, fifty per cent.
(2) The efficiency incentive payment rate for an ICF/IID with eight or fewer beds shall not exceed three dollars per medicaid day, adjusted annually in accordance with division (G) of this section. For the purpose of determining an ICF/IID's efficiency incentive payment rate, both of the following apply:
(a) Depreciation for costs paid or reimbursed by any government agency shall be considered as a cost of ownership;
(b) The applicable limit under division (B) of this section shall apply both to ICFs/IID with more than eight beds and ICFs/IID with eight or fewer beds.
(F) An ICF/IID's return on net equity shall be determined at the rate of one and one-half times the average of interest rates on special issues of public debt obligations issued to the federal hospital insurance trust fund for the cost reporting period. In determining an ICF/IID's rate for return on net equity, the department shall use the greater of the ICF/IID's inpatient days during the applicable cost reporting period or the number of inpatient days the ICF/IID would have had during that period if the ICF/IID's occupancy rate had been ninety-five per cent. No ICF/IID's rate for return on net equity shall exceed one dollar per medicaid day. No ICF/IID's rate for capital costs shall include a rate for return on net equity beginning July 1, 2014.
(G) The amounts specified in divisions (B), (C) , (D), and (E) of this section shall be adjusted beginning July 1, 1993, for the estimated inflation rate for the twelve-month period beginning on the first day of July of the calendar year immediately preceding the calendar year that immediately precedes the fiscal year for which rate will be paid and ending on the thirtieth day of the following June, using the consumer price index for shelter costs for all urban consumers for the midwest region, as published by the United States bureau of labor statistics.
(H) Notwithstanding divisions (C) and (D) of this section, the total payment rate for costs of ownership, capitalized costs of nonextensive renovations, and the efficiency incentive for an ICF/IID with eight or fewer beds shall not exceed the sum of the limitations specified in divisions (C) and (D) of this section.
(1) For the purpose of determining ICFs/IID's medicaid payment rates for capital costs:
(a) Buildings shall be depreciated using the straight line method over forty years or over a different period approved by the department.
(b) Components and equipment shall be depreciated using the straight line method over a period designated by the director of developmental disabilities in rules adopted under section 5124.03 of the Revised Code, consistent with the guidelines of the American hospital association, or over a different period approved by the department.
(2) Any rules authorized by division (I)(1) of this section that specify useful lives of buildings, components, or equipment apply only to assets acquired on or after July 1, 1993. Depreciation for costs paid or reimbursed by any government agency shall not be included in costs of ownership or costs of nonextensive renovations unless that part of the payment under this chapter is used to reimburse the government agency.
(1) Except as provided in division (J)(2) of this section, if a provider leases or transfers an interest in an ICF/IID to another provider who is a related party, the related party's allowable costs of ownership shall include the lesser of the following:
(a) The annual lease expense or actual cost of ownership, whichever is applicable;
(b) The reasonable cost to the lessor or provider making the transfer.
(2) If a provider leases or transfers an interest in an ICF/IID to another provider who is a related party, regardless of the date of the lease or transfer, the related party's allowable cost of ownership shall include the annual lease expense or actual cost of ownership, whichever is applicable, subject to the limitations specified in divisions (B) to (I) of this section, if all of the following conditions are met:
(a) The related party is a relative of owner;
(b) In the case of a lease, if the lessor retains any ownership interest, it is, except as provided in division (J)(2)(d)(ii) of this section, in only the real property and any improvements on the real property;
(c) In the case of a transfer, the provider making the transfer retains, except as provided in division (J)(2)(d)(iv) of this section, no ownership interest in the ICF/IID;
(d) The department determines that the lease or transfer is an arm's length transaction pursuant to rules adopted under section 5124.03 of the Revised Code. The rules shall provide that a lease or transfer is an arm's length transaction if all of the following, as applicable, apply:
(i) In the case of a lease, once the lease goes into effect, the lessor has no direct or indirect interest in the lessee or, except as provided in division (J)(2)(b) of this section, the ICF/IID itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a lessor.
(ii) In the case of a lease, the lessor does not reacquire an interest in the ICF/IID except through the exercise of a lessor's rights in the event of a default. If the lessor reacquires an interest in the ICF/IID in this manner, the department shall treat the ICF/IID as if the lease never occurred when the department determines its payment rate for capital costs.
(iii) In the case of a transfer, once the transfer goes into effect, the provider that made the transfer has no direct or indirect interest in the provider that acquires the ICF/IID or the ICF/IID itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a creditor.
(iv) In the case of a transfer, the provider that made the transfer does not reacquire an interest in the ICF/IID except through the exercise of a creditor's rights in the event of a default. If the provider reacquires an interest in the ICF/IID in this manner, the department shall treat the ICF/IID as if the transfer never occurred when the department determines its payment rate for capital costs.
(v) The lease or transfer satisfies any other criteria specified in the rules.
(e) Except in the case of hardship caused by a catastrophic event, as determined by the department, or in the case of a lessor or provider making the transfer who is at least sixty-five years of age, not less than twenty years have elapsed since, for the same ICF/IID, allowable cost of ownership was determined most recently under this division.
Renumbered from § 5111.251 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Amended by 128th General Assemblych.28, SB 79, §1, eff. 10/6/2009.
Effective Date: 06-06-2001; 07-01-2005
(A) (1) For each fiscal year, the department of developmental disabilities shall determine each ICF/IID's per medicaid day payment rate for direct care costs as follows:
(a) Multiply the lesser of the following by the ICF/IID's annual average case-mix score determined or assigned under section 5124.192 of the Revised Code for the calendar year immediately preceding the fiscal year for which the rate will be paid:
(i) The ICF/IID's cost per case-mix unit for the calendar year immediately preceding the fiscal year for which the rate will be paid, as determined under division (B) of this section;
(ii) The maximum cost per case-mix unit for the ICF/IID's peer group for the fiscal year for which the rate will be paid, as set under division (C) of this section;
(b) Adjust the product determined under division (A)(1)(a) of this section by the inflation rate estimated under division (D)(1) of this section and modified under division (D)(2) of this section.
(2) Except as otherwise directed by law enacted by the general assembly, the department shall determine each ICF/IID's rate for direct care costs prospectively.
(B) To determine
an ICF/IID's cost per case-mix unit for the calendar year immediately preceding the fiscal year in which the rate will be paid , the department shall divide the ICF/IID's desk-reviewed, actual, allowable, per diem direct care costs for that calendar year by its annual average case-mix score determined under section 5124.192 of the Revised Code for the same calendar year.
(1) For each fiscal year for which a rate will be paid, the department shall set the maximum cost per case-mix unit for each peer group of ICFs/IID with more than eight beds at a percentage above the cost per case-mix unit determined under division (B) of this section for the ICF/IID in the peer group that has the peer group's median number of medicaid days for the calendar year immediately preceding the fiscal year in which the rate will be paid . The percentage shall be no less than the percentage above the cost per case-mix unit determined under division (B) of this section for the ICF/IID that has the median number of medicaid days for calendar year 1992 for all ICFs/IID with more than eight beds that would result in payment of all desk-reviewed, actual, allowable direct care costs for eighty and one-half per cent of the medicaid days for such ICFs/IID for calendar year 1992.
(2) For each fiscal year for which a rate will be paid, the department shall set the maximum cost per case-mix unit for each peer group of ICFs/IID with eight or fewer beds at a percentage above the cost per case-mix unit determined under division (B) of this section for the ICF/IID in the peer group that has the peer group's median number of medicaid days for the calendar year immediately preceding the fiscal year in which the rate will be paid . The percentage shall be no less than the percentage above the cost per case-mix unit determined under division (B) of this section for the ICF/IID that has the median number of medicaid days for calendar year 1992 for all ICFs/IID with eight or fewer beds that would result in payment of all desk-reviewed, actual, allowable direct care costs for eighty and one-half per cent of the medicaid days for such ICFs/IID for calendar year 1992.
(3) In determining the maximum cost per case-mix unit under divisions (C)(1) and (2) of this section for each peer group, the department shall exclude from its determinations the cost per case-mix unit of any ICF/IID in the peer group that participated in the medicaid program under the same provider for less than twelve months during the calendar year immediately preceding the fiscal year in which the rate will be paid.
(4) The department shall not reset a peer group's maximum cost per case-mix unit for a fiscal year under division (C)(1) or (2) of this section based on additional information that it receives after it sets the maximum for that fiscal year. The department shall reset a peer group's maximum cost per case-mix unit for a fiscal year only if it made an error in setting the maximum for that fiscal year based on information available to the department at the time it originally sets the maximum for that fiscal year.
(1) The department shall estimate the rate of inflation for the eighteen-month period beginning on the first day of July of the calendar year preceding the fiscal year in which a rate will be paid and ending on the thirty-first day of December of the fiscal year in which the rate will be paid, using the
following :
(a) Subject to division (D)(1)(b) of this section, the employment cost index for total compensation, health care and social assistance component, published by the United States bureau of labor statistics;
(b) If the United States bureau of labor statistics ceases to publish the index specified in division (D)(1)(a) of this section, the index that is subsequently published by the bureau and covers the staff costs of ICFs/IID.
(2) If the estimated inflation rate for the eighteen-month period specified in division (D)(1) of this section is different from the actual inflation rate for that period, as measured using the same index, the difference shall be added to or subtracted from the inflation rate estimated under division (D)(1) of this section for the following fiscal year.
(E) The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code that specify peer groups of ICFs/IID with more than eight beds and peer groups of ICFs/IID with eight or fewer beds, based on findings of significant per diem direct care cost differences due to geography and bed-size. The rules also may specify peer groups based on findings of significant per diem direct care cost differences due to other factors which may include case-mix.
Renumbered from § 5111.23 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 9/10/2012.
Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Effective Date: 07-01-2000; 07-01-2005
Each calendar quarter, each ICF/IID provider shall compile complete assessment data for each resident of each of the provider's ICFs/IID, regardless of payment source, who is in the ICF/IID, or on hospital or therapeutic leave from the ICF/IID, on the last day of the quarter. A resident assessment instrument specified in rules adopted under section 5124.03 of the Revised Code shall be used to compile the resident assessment data. Each provider shall submit the resident assessment data to the department of developmental disabilities not later than fifteen days after the end of the calendar quarter for which the data is compiled. The resident assessment data shall be submitted to the department through the medium or media specified in rules adopted under section 5124.03 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Except as provided in division (B) of this section, the department of developmental disabilities shall do both of the following:
(1) For each calendar quarter, determine a case-mix score for each ICF/IID using the resident assessment data submitted to the department under section 5124.191 of the Revised Code and the grouper methodology prescribed in rules authorized by this section;
(2) After the end of each calendar year and in accordance with rules authorized by this section, determine an annual average case-mix score for each ICF/IID using the ICF/IID's quarterly case-mix scores for that calendar year.
(1) Subject to division (B)(2) of this section, the department, for one or more months of a calendar quarter, may assign to an ICF/IID a case-mix score that is five per cent less than the ICF/IID's case-mix score for the immediately preceding calendar quarter if any of the following apply:
(a) The provider does not timely submit complete and accurate resident assessment data necessary to determine the ICF/IID's case-mix score for the calendar quarter;
(b) The ICF/IID was subject to an exception review under section 5124.193 of the Revised Code for the immediately preceding calendar quarter;
(c) The ICF/IID was assigned a case-mix score for the immediately preceding calendar quarter.
(2) Before assigning a case-mix score to an ICF/IID due to the submission of incorrect resident assessment data, the department shall permit the provider to correct the data. The department may assign the case-mix score if the provider fails to submit the corrected resident assessment data not later than forty-five days after the end of the calendar quarter to which the data pertains or later due date specified in rules authorized by this section.
(3) If, for more than six months during a calendar year, a provider is paid a rate determined for an ICF/IID using a case-mix score assigned to the ICF/IID under division (B)(1) of this section, the department may assign the ICF/IID a cost per case-mix unit that is five per cent less than the ICF/IID's actual or assigned cost per case-mix unit for the immediately preceding calendar year. The department may use the assigned cost per case-mix unit, instead of determining the ICF/IID's actual cost per case-mix unit in accordance with section 5124.19 of the Revised Code, to establish the ICF/IID's rate for direct care costs for the fiscal year immediately following the calendar year for which the cost per case-mix unit is assigned.
(4) The department shall take action under division (B)(1), (2), or (3) of this section only in accordance with rules authorized by this section. The department shall not take an action that affects medicaid payment rates for prior payment periods except in accordance with sections 5124.41 and 5124.42 of the Revised Code.
(C) The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code as necessary to implement this section.
(1) The rules shall do all of the following:
(a) Prescribe a grouper methodology to be used when determining the case-mix scores for ICFs/IID;
(b) Specify the process for determining the annual average case-mix scores for ICFs/IID;
(c) Establish procedures under which resident assessment data is to be reviewed for accuracy and providers are to be notified of any data that requires correction;
(d) Establish procedures for providers to correct resident assessment data and, if necessary, specify a due date for corrections that is later than the due date specified in division (B)(2) of this section.
(e) Specify when and how the department will assign a case-mix score or cost per case-mix unit to an ICF/IID under division (B) of this section if information necessary to calculate the ICF/IID's case-mix score is not provided or corrected in accordance with the procedures established by the rules.
(2) Notwithstanding any other provision of this chapter, the rules may provide for excluding case-mix scores assigned to an ICF/IID under division (B) of this section from the determination of the ICF/IID's annual average case-mix score and the maximum cost per case-mix unit for the ICF/IID's peer group.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) The department of developmental disabilities may, pursuant to rules authorized by this section, conduct an exception review of resident assessment data submitted by an ICF/IID provider under section 5124.191 of the Revised Code. The department may conduct an exception review based on the findings of a medicaid certification survey conducted by the department of health, a risk analysis, or prior performance of the provider.
Exception reviews shall be conducted at the ICF/IID by appropriate health professionals under contract with or employed by the department. The professionals may review resident assessment forms and supporting documentation, conduct interviews, and observe residents to identify any patterns or trends of inaccurate resident assessments and resulting inaccurate case-mix scores.
(B) If an exception review is conducted before the effective date of an ICF/IID's rate for direct care costs that is based on the resident assessment data being reviewed and the review results in findings that exceed tolerance levels specified in the rules authorized by this section, the department, in accordance with the rules authorized by this section, may use the findings to redetermine individual resident case-mix scores, the ICF/IID's case-mix score for the quarter, and the ICF/IID's annual average case-mix score. The department may use the ICF/IID's redetermined quarterly and annual average case-mix scores to determine the ICF/IID's rate for direct care costs for the appropriate calendar quarter or quarters.
(C) The department shall prepare a written summary of any exception review finding that is made after the effective date of an ICF/IID's rate for direct care costs that is based on the resident assessment data that was reviewed. Where the provider is pursuing judicial or administrative remedies in good faith regarding the finding, the department shall not withhold from the provider's current payments any amounts the department claims to be due from the provider pursuant to section 5124.41 of the Revised Code.
(1) The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code as necessary to implement this section. The rules shall establish an exception review program that does all of the following:
(a) Requires each exception review to comply with Title XIX;
(b) Requires a written summary for each exception review that states whether resident assessment forms have been completed accurately;
(c) Prohibits each health professional who conducts an exception review from doing either of the following:
(i) During the period of the professional's contract or employment with the department, having or being committed to acquire any direct or indirect financial interest in the ownership, financing, or operation of ICFs/IID in this state;
(ii) Reviewing any provider that has been a client of the professional.
(2) For the purposes of division (D)(1)(c)(i) of this section, employment of a member of a health professional's family by an ICF/IID that the professional does not review does not constitute a direct or indirect financial interest in the ownership, financing, or operation of the ICF/IID.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The costs of day programming shall be part of the direct care costs of an ICF/IID as off-site day programming if the area in which the day programming is provided is not certified by the director of health as an ICF/IID under Title XIX and regardless of either of the following:
(A) Whether or not the area in which the day programming is provided is less than two hundred feet away from the ICF/IID;
(B) Whether or not the day programming is provided by an individual who, or organization that, is a related party to the provider of the ICF/IID.
Renumbered from § 5111.233 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Added by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.
(A) For each fiscal year, the department of developmental disabilities shall determine each ICF/IID's per medicaid day payment rate for indirect care costs . Except as otherwise provided in this chapter, an ICF/IID's rate shall be determined prospectively. Subject to section 5124.28 of the Revised Code, an ICF/IID's rate shall be the lesser of the individual rate determined under division (B) of this section and the maximum rate determined for the ICF/IID's peer group under division (C) of this section.
(B) An ICF/IID's individual rate is the sum of the following:
(1) The ICF/IID's desk-reviewed, actual, allowable, per diem indirect care costs from the calendar year immediately preceding the fiscal year in which the rate will be paid, adjusted for the inflation rate estimated under division (D)(1) of this section;
(2) If the ICF/IID has more than eight beds, an efficiency incentive in the following amount:
(a) For fiscal
year 2014, seven and one-tenth per cent of the maximum rate established for the ICF/IID's peer group under division (C) of this section;
(b) For fiscal year 2015, the following amount:
(i) The amount calculated for fiscal year 2014 under division (B)(2)(a) of this section if the provider of the ICF/IID obtains the department's approval to become a downsized ICF/IID and the approval is conditioned on the downsizing being completed not later than July 1, 2018;
(ii) One-half of the amount calculated for fiscal year 2014 under division (B)(2)(a) of this section if division (B)(2)(b)(i) of this section does not apply to the ICF/IID.
(c) For fiscal year 2016 and each fiscal year thereafter ending in an even-numbered calendar year, the following percentages of the maximum rate established for the ICF/IID's peer group under division (C) of this section:
(i) Seven and one-tenth per cent if the provider of the ICF/IID obtains the department's approval to become a downsized ICF/IID and the approval is conditioned on the downsizing being completed not later than July 1, 2018;
(ii) Three and fifty-five hundredths per cent if division (B)(2)(c)(i) of this section does not apply to the ICF/IID.
(d) For fiscal year 2017 and each fiscal year thereafter ending in an odd-numbered calendar year, the amount calculated for the immediately preceding fiscal year under division (B)(2)(c) of this section.
(3) If the ICF/IID has eight or fewer beds, an efficiency incentive in the following amount:
(a) For each fiscal year ending in an even-numbered calendar year, seven per cent of the maximum rate established for the ICF/IID's peer group under division (C) of this section;
(b) For each fiscal year ending in an odd-numbered calendar year, the amount calculated for the immediately preceding fiscal year under division (B)(3)(a) of this section.
(C) (1) The maximum rate for indirect care costs for each peer group of ICFs/IID with more than eight beds shall be determined as follows:
(a) For each fiscal year ending in an even-numbered calendar year, the maximum rate for each such peer group shall be the rate that is no less than twelve and four-tenths per cent above the median desk-reviewed, actual, allowable, per diem indirect care cost for all ICFs/IID in the peer group (excluding ICFs/IID in the peer group whose indirect care costs for that period are more than three standard deviations from the mean desk-reviewed, actual, allowable, per diem indirect care cost for all ICFs/IID with more than eight beds ) for the calendar year immediately preceding the fiscal year in which the rate will be paid, adjusted by the inflation rate estimated under division (D)(1) of this section.
(b) For each fiscal year ending in an odd-numbered calendar year, the maximum rate for each such peer group is the peer group's maximum rate for the previous fiscal year, adjusted for the inflation rate estimated under division (D)(2) of this section.
(2) The maximum rate for indirect care costs for each peer group of ICFs/IID with eight or fewer beds shall be determined as follows:
(a) For each fiscal year ending in an even-numbered calendar year, the maximum rate for each such peer group shall be the rate that is no less than ten and three-tenths per cent above the median desk-reviewed, actual, allowable, per diem indirect care cost for all ICFs/IID in the peer group (excluding ICFs/IID in the peer group whose indirect care costs are more than three standard deviations from the mean desk-reviewed, actual, allowable, per diem indirect care cost for all ICFs/IID with eight or fewer beds ) for the calendar year immediately preceding the fiscal year in which the rate will be paid, adjusted by the inflation rate estimated under division (D)(1) of this section.
(b) For each fiscal year ending in an odd-numbered calendar year, the maximum rate for each such peer group is the peer group's maximum rate for the previous fiscal year, adjusted for the inflation rate estimated under division (D)(2) of this section.
(3) The department shall not redetermine a maximum rate for indirect care costs under division (C)(1) or (2) of this section based on additional information that it receives after the maximum rate is set. The department shall redetermine the maximum rate for indirect care costs only if it made an error in computing the maximum rate based on the information available to the department at the time of the original calculation.
(D) (1) When adjusting rates for inflation under divisions (B)(1), (C)(1)(a), and (C)(2)(a) of this section, the department shall estimate the rate of inflation for the eighteen-month period beginning on the first day of July of the calendar year immediately preceding the fiscal year in which the rate will be paid and ending on the thirty-first day of December of the fiscal year in which the rate will be paid. To estimate the rate of inflation, the department shall use the following:
(a) Subject to division (D)(1)(b) of this section, the consumer price index for all items for all urban consumers for the midwest region, published by the United States bureau of labor statistics;
(b) If the United States bureau of labor statistics ceases to publish the index specified in division (D)(1)(a) of this section, a comparable index that the bureau publishes and the department determines is appropriate.
(2) When adjusting rates for inflation under divisions (C)(1)(b) and (C)(2)(b) of this section, the department shall estimate the rate of inflation for the twelve-month period beginning on the first day of January of the fiscal year immediately preceding the fiscal year in which the rate will be paid and ending on the thirty-first day of December of the fiscal year in which the rate will be paid. To estimate the rate of inflation, the department shall use the following:
(a) Subject to division (D)(2)(b) of this section, the consumer price index for all items for all urban consumers for the midwest region, published by the United States bureau of labor statistics;
(b) If the United States bureau of labor statistics ceases to publish the index specified in division (D)(2)(a) of this section, a comparable index that the bureau publishes and the department determines is appropriate.
(3) If an inflation rate estimated under division (D)(1) or (2) of this section is different from the actual inflation rate for the relevant time period, as measured using the same index, the difference shall be added to or subtracted from the inflation rate estimated pursuant to this division for the following fiscal year.
(E) The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code that specify peer groups of ICFs/IID with more than eight beds and peer groups of ICFs/IID with eight or fewer beds, based on findings of significant per diem indirect care cost differences due to geography and bed-size. The rules also may specify peer groups based on findings of significant per diem indirect care cost differences due to other factors, including case-mix.
Renumbered from § 5111.241 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Effective Date: 07-01-2000; 07-01-2005
(A) For each fiscal year, the department of developmental disabilities shall determine each ICF/IID's per medicaid day payment rate for other protected costs . Except as otherwise provided in this chapter, an ICF/IID's rate shall be determined prospectively. An ICF/IID's rate shall be the ICF/IID's desk-reviewed, actual, allowable, per diem other protected costs from the calendar year immediately preceding the fiscal year in which the rate will be paid, all adjusted for the estimated inflation rate for the eighteen-month period beginning on the first day of July of the calendar year immediately preceding the fiscal year in which the rate will be paid and ending on the thirty-first day of December of that fiscal year. The department shall estimate inflation using the index specified in division (B) of this section. If the estimated inflation rate for the eighteen-month period is different from the actual inflation rate for that period, the difference shall be added to or subtracted from the inflation rate estimated for the following year.
(B) The department shall use the following index for the purpose of division (A) of this section:
(1) Subject to division (B)(2) of this section, the consumer price index for all urban consumers for nonprescription drugs and medical supplies, as published by the United States bureau of labor statistics;
(2) If the United States bureau of labor statistics ceases to publish the index specified in division (B)(1) of this section, the index that is subsequently published by the bureau and covers nonprescription drugs and medical supplies.
Renumbered from § 5111.235 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Effective Date: 07-01-2000; 07-01-2005
(A) Subject to division (D) of this section, the department of developmental disabilities may pay a medicaid rate add-on to an ICF/IID provider for outlier ICF/IID services the ICF/IID provides to qualifying ventilator-dependent residents on or after the effective date of this section, if the provider applies to the department of developmental disabilities to receive the rate add-on and the department approves the application. The department of developmental disabilities may approve a provider's application if both of the following apply:
(1) The provider submits to the department of developmental disabilities a best practices protocol for providing outlier ICF/IID services under this section and the department of developmental disabilities determines that the protocol is acceptable;
(2) The provider and ICF/IID meet all other eligibility requirements for the rate add-on established in rules authorized by this section.
(B) An ICF/IID that has been approved by the department of developmental disabilities to provider outlier ICF/IID services under this section shall provide the services in accordance with both of the following:
(1) The best practices protocol the department of developmental disabilities determined is acceptable;
(2) Requirements regarding the services established in rules authorized by this section.
(C) To qualify to receive outlier ICF/IID services from an ICF/IID under this section, a resident of the ICF/IID must be a medicaid recipient, be under twenty-two years of age, be dependent on a ventilator, and meet all other eligibility requirements established in rules authorized by this section.
(D) The department of developmental disabilities shall negotiate the amount of the medicaid payment rate add-on, if any, to be paid under this section, or the method by which that amount is to be determined, with the department of medicaid. The department of developmental disabilities shall not pay the rate add-on unless the department of medicaid has approved the amount of the rate add-on or method by which the amount is to be determined.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Notwithstanding any provision of section 5124.17 or 5124.21 of the Revised Code, the director of developmental disabilities may adopt rules under section 5124.03 of the Revised Code that provide for the determination of a combined maximum payment limit for indirect care costs and costs of ownership for ICFs/IID with eight or fewer beds.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Except as otherwise provided in section 5124.30 of the Revised Code, the department of developmental disabilities, in determining whether an ICF/IID's direct care costs and indirect care costs are allowable, shall place no limit on specific categories of reasonable costs other than compensation of owners, compensation of relatives of owners, and compensation of administrators.
Compensation cost limits for owners and relatives of owners shall be based on compensation costs for individuals who hold comparable positions but who are not owners or relatives of owners, as reported on ICFs/IID's cost reports. As used in this section, "comparable position" means the position that is held by the owner or the owner's relative, if that position is listed separately on the cost report form, or if the position is not listed separately, the group of positions that is listed on the cost report form and that includes the position held by the owner or the owner's relative. In the case of an owner or owner's relative who serves the ICFs/IID in a capacity such as corporate officer, proprietor, or partner for which no comparable position or group of positions is listed on the cost report form, the compensation cost limit shall be based on civil service equivalents and shall be specified in rules adopted under section 5124.03 of the Revised Code.
Compensation cost limits for administrators shall be based on compensation costs for administrators who are not owners or relatives of owners, as reported on ICFs/IID's cost reports. Compensation cost limits for administrators of four or more ICFs/IID shall be the same as the limits for administrators of ICFs/IID with one hundred fifty or more beds.
Renumbered from § 5111.263 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Renumbered from § 5111.261 by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Amended by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 10/16/2009.
Effective Date: 07-01-2000; 07-01-2005
Except as provided in section 5124.17 of the Revised Code, the costs of goods, services, and facilities, furnished to an ICF/IID provider by a related party are includable in the allowable costs of the provider at the reasonable cost to the related party.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities shall adjust medicaid payment rates determined under this chapter to account for reasonable additional costs that must be incurred by ICFs/IID to comply with requirements of federal or state statutes, rules, or policies enacted or amended after January 1, 1992, or with orders issued by state or local fire authorities.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities shall not reduce an ICF/IID's medicaid payment rate determined under this chapter on the basis that the provider charges a lower rate to any resident who is not eligible for medicaid.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
No medicaid payment shall be made to an ICF/IID provider for the day a medicaid recipient is discharged from the ICF/IID.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) The department of developmental disabilities shall pay an ICF/IID provider one hundred per cent of the total per medicaid day payment rate determined for the ICF/IID under this chapter to reserve a bed for a resident who is a medicaid recipient if all of the following apply:
(1) The recipient is temporarily absent from the ICF/IID for a reason that makes the absence qualified for payments under this section as specified in rules authorized by this section;
(2) The resident's plan of care provides for the absence ;
(3) Federal financial participation is available for the payments.
(B) The maximum period during which medicaid payments may be made to reserve a bed shall not exceed the maximum period specified in federal regulations and shall not be more than thirty days during any calendar year for hospital stays, visits with relatives and friends, and participation in therapeutic
programs. However, a resident shall not be subject to a maximum period during which payments may be made to reserve a bed if prior authorization of the department is obtained for hospital stays, visits with relatives and friends, and participation in therapeutic programs.
(1) The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code as necessary to implement this section, including rules that do the following:
(a) Specify the reasons for which a temporary absence from an ICF/IID makes the absence qualify for payments under this section;
(b) Establish conditions under which prior authorization may be obtained for the purpose of division (B) of this section.
(2) The rules authorized by division (C)(1)(a) of this section shall include the following as reasons for which a temporary absence from an ICF/IID qualifies for payments under this section:
(a) Hospitalization for acute conditions;
(b) Visits with relatives and friends;
(c) Participation in therapeutic programs outside the ICF/IID.
Renumbered from § 5111.33 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Effective Date: 07-01-2000; 07-01-2005
Medicaid payments may be made for ICF/IID services provided not later than thirty days after the effective date of an involuntary termination of the ICF/IID that provides the services if the services are provided to a medicaid recipient who is eligible for the services and resided in the ICF/IID before the effective date of the involuntary termination.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities shall make its best efforts each year to determine ICFs/IID's medicaid payment rates under this chapter in time to pay the rates by August fifteenth of each fiscal year. If the department is unable to calculate the rates so that they can be paid by that date, the department shall pay each provider the rate calculated for the provider's ICFs/IID under those sections at the end of the previous fiscal year. If the department also is unable to calculate the rates to make the payments due by the fifteenth day of September and the fifteenth day of October, the department shall pay the previous fiscal year's rate to make those payments. The department may increase by five per cent the previous fiscal year's rate paid for any ICF/IID pursuant to this section at the request of the provider. The department shall use rates calculated for the current fiscal year to make the payments due by the fifteenth day of November.
If an ICF/IID's medicaid payment rate paid under this section is lower than the rate calculated for it for the current fiscal year, the department shall pay the provider the difference between the two rates for the number of days for which the provider is paid the lower rate. If an ICF/IID's medicaid payment rate paid under this section is higher than the rate calculated for it for the current fiscal year, the provider shall refund to the department the difference between the two rates for the number of days for which the provider is paid the higher rate.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) The director of developmental disabilities shall establish a process under which an ICF/IID provider, or a group or association of ICF/IID providers, may seek reconsideration of medicaid payment rates established under this chapter, including a rate for direct care costs redetermined before the effective date of the rate as a result of an exception review conducted under section 5124.193 of the Revised Code. Except as provided in divisions (B) to (D) of this section, the only issue that a provider, group, or association may raise in the rate reconsideration is whether the rate was calculated in accordance with this chapter and the rules adopted under section 5124.03 of the Revised Code. The provider, group, or association may submit written arguments or other materials that support its position. The provider, group, or association and department shall take actions regarding the rate reconsideration within time frames specified in rules authorized by this section.
If the department determines, as a result of the rate reconsideration, that the rate established for one or more ICFs/IID is less than the rate to which the ICF/IID is entitled, the department shall increase the rate. If the department has paid the incorrect rate for a period of time, the department shall pay the provider of the ICF/IID the difference between the amount the provider was paid for that period for the ICF/IID and the amount the provider should have been paid for the ICF/IID.
(1) The department, through the rate reconsideration process, may increase during a fiscal year the medicaid payment rate determined for an ICF/IID under this chapter if the provider demonstrates that the ICF/IID's actual, allowable costs have increased because of any of the following extreme circumstances:
(a) A natural disaster;
(b) A nonextensive renovation approved under division (D) of section 5124.17 of the Revised Code;
(c) If the ICF/IID has an appropriate claims management program, an increase in the ICF/IID's workers' compensation experience rating of greater than five per cent;
(d) If the ICF/IID is an inner-city ICF/IID, increased security costs;
(e) A change of ownership that results from bankruptcy, foreclosure, or findings by the department of health of violations of medicaid certification requirements;
(f) Other extreme circumstances specified in rules authorized by this section.
(2) An ICF/IID may qualify for a rate increase under this division only if its per diem, actual, allowable costs have increased to a level that exceeds its total rate. An increase under this division is subject to any rate limitations or maximum rates established by this chapter for specific cost centers. Any rate increase granted under this division shall take effect on the first day of the first month after the department receives the request.
(C) The department, through the rate reconsideration process, may increase an ICF/IID's rate as determined under this chapter if the department, in the department's sole discretion, determines that the rate as determined under those sections works an extreme hardship on the ICF/IID.
(D) When beds certified for the medicaid program are added to an existing ICF/IID or replaced at the same site, the department, through the rate reconsideration process, may increase the ICF/IID's rate for capital costs proportionately, as limited by any applicable limitation under section 5124.17 of the Revised Code, to account for the costs of the beds that are added or replaced. If the department makes this increase, it shall make the increase one month after the first day of the month after the department receives sufficient documentation of the costs. Any rate increase granted under this division after June 30, 1993, shall remain in effect until the effective date of a rate for capital costs determined under section 5124.17 of the Revised Code that includes costs incurred for a full calendar year for the bed addition or bed replacement. The ICF/IID shall report double accumulated depreciation in an amount equal to the depreciation included in the rate adjustment on its cost report for the first year of operation. During the term of any loan used to finance a project for which a rate adjustment is granted under this division, if the ICF/IID is operated by the same provider, the provider shall subtract from the interest costs it reports on its cost report an amount equal to the difference between the following:
(1) The actual, allowable interest costs for the loan during the calendar year for which the costs are being reported;
(2) The actual, allowable interest costs attributable to the loan that were used to calculate the rates paid to the provider for the ICF/IID during the same calendar year.
(E) The department's decision at the conclusion of the reconsideration process is not subject to any administrative proceedings under Chapter 119. or any other provision of the Revised Code.
(F) The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code as necessary to implement this section.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
If an ICF/IID provider properly amends a cost report for an ICF/IID under section 5124.107 of the Revised Code and the amended report shows that the provider received a lower medicaid payment rate under the original cost report than the provider was entitled to receive, the department of developmental disabilities shall adjust the provider's rate for the ICF/IID prospectively to reflect the corrected information. The department shall pay the adjusted rate beginning two months after the first day of the month after the provider files the amended cost report.
If the department finds, from an exception review of resident assessment data conducted pursuant to section 5124.193 of the Revised Code after the effective date of an ICF/IID's rate for direct care costs that is based on the resident assessment data, that inaccurate resident assessment data resulted in the provider receiving a lower rate for the ICF/IID than the provider was entitled to receive, the department prospectively shall adjust the provider's rate for the ICF/IID accordingly. The department shall make payments to the provider using the adjusted rate for the remainder of the calendar quarter for which the resident assessment data is used to determine the rate, beginning one month after the first day of the month after the exception review is completed.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) The department of developmental disabilities shall redetermine a provider's medicaid payment rate for an ICF/IID using revised information if any of the following results in a determination that the provider received a higher medicaid payment rate for the ICF/IID than the provider was entitled to receive:
(1) The provider properly amends a cost report for the ICF/IID under section 5124.107 of the Revised Code;
(2) The department makes a finding based on an audit under section 5124.109 of the Revised Code;
(3) The department makes a finding based on an exception review of resident assessment data conducted under section 5124.193 of the Revised Code after the effective date of the ICF/IID's rate for direct care costs that is based on the resident assessment data.
(B) The department shall apply the redetermined rate to the periods when the provider received the incorrect rate to determine the amount of the overpayment. The provider shall refund the amount of the overpayment. The department may charge the provider the following amount of interest from the time the overpayment was made:
(1) If the overpayment resulted from costs reported for calendar year 1993, the interest shall be not greater than one and one-half times the current average bank prime rate.
(2) If the overpayment resulted from costs reported for a subsequent calendar year:
(a) The interest shall be not greater than two times the current average bank prime rate if the overpayment was not more than one per cent of the total medicaid payments to the provider for the fiscal year for which the incorrect information was used to determine a rate.
(b) The interest shall be not greater than two and one-half times the current average bank prime rate if the overpayment was more than one per cent of the total medicaid payments to the provider for the fiscal year for which the incorrect information was used to determine a rate.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
In addition to the other penalties authorized by this chapter, the department of developmental disabilities may impose the following penalties on an ICF/IID provider:
(A) If the provider does not furnish invoices or other documentation that the department requests during an audit within sixty days after the request, a fine of not more than the greater of the following:
(1) One thousand dollars per audit;
(2) Twenty-five per cent of the cumulative amount by which the costs for which documentation was not furnished increased the total medicaid payments to the provider during the fiscal year for which the costs were used to determine a rate.
(B) If an exiting operator or owner fails to provide notice of a facility closure or voluntary termination as required by section 5124.50 of the Revised Code, or an exiting operator or owner and entering operator fail to provide notice of a change of operator as required by section 5124.51 of the Revised Code, a fine of not more than the current average bank prime rate plus four per cent of the last two monthly payments.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
For the purposes of sections 5124.41 and 5124.42 of the Revised Code, the department of developmental disabilities shall determine the current average bank prime rate using statistical release H.15, "selected interest rates," a weekly publication of the federal reserve board, or any successor publication. If statistical release H.15, or its successor, ceases to contain the bank prime rate information or ceases to be published, the department shall request a written statement of the average bank prime rate from the federal reserve bank of Cleveland or the federal reserve board.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Except as provided in division (B) of this section, the department of developmental disabilities shall deduct the following from the next available medicaid payment the department makes to an ICF/IID provider who continues to participate in medicaid:
(1) Any amount the provider is required to refund, and any interest charged, under section 5124.41 of the Revised Code;
(2) The amount of any penalty imposed on the provider under section 5124.42 of the Revised Code.
(B) The department and an ICF/IID provider may enter into an agreement under which a deduction required by division (A) of this section is taken in installments from payments the department makes to the provider.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities shall transmit to the treasurer of state for deposit in the general revenue fund amounts collected from the following:
(A) Refunds required by, and interest charged under, section 5124.41 of the Revised Code;
(B) Amounts collected from penalties imposed under section 5124.42 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
All of the following are subject to an adjudication conducted in accordance with Chapter 119. of the Revised Code:
(A) Any audit disallowance that the department of developmental disabilities makes as the result of an audit under section 5124.109 of the Revised Code;
(B) Any adverse finding that results from an exception review of resident assessment data conducted for an ICF/IID under section 5124.193 of the Revised Code after the effective date of the ICF/IID's medicaid payment rate for direct care costs that is based on the resident assessment data;
(C) Any medicaid payment deemed an overpayment under section 5124.523 of the Revised Code;
(D) Any penalty the department imposes under section 5124.42 of the Revised Code or section 5124.523 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
An exiting operator or owner of an ICF/IID participating in the medicaid program shall provide the department of developmental disabilities and department of medicaid written notice of a facility closure or voluntary termination not less than ninety days before the effective date of the facility closure or voluntary termination. The written notice shall be provided to the department of developmental disabilities and department of medicaid in accordance with the method specified in rules authorized by section 5124.53 of the Revised Code.
The written notice shall include all of the following:
(A) The name of the exiting operator and, if any, the exiting operator's authorized agent;
(B) The name of the ICF/IID that is the subject of the written notice;
(C) The exiting operator's medicaid provider agreement number for the ICF/IID that is the subject of the written notice;
(D) The effective date of the facility closure or voluntary termination;
(E) The signature of the exiting operator's or owner's representative.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) An exiting operator or owner and entering operator shall provide the department of developmental disabilities and department of medicaid written notice of a change of operator if the ICF/IID participates in the medicaid program and the entering operator seeks to continue the ICF/IID's participation. The written notice shall be provided to the department of developmental disabilities and department of medicaid in accordance with the method specified in rules authorized by section 5124.53 of the Revised Code. The written notice shall be provided to the department of developmental disabilities and department of medicaid not later than forty-five days before the effective date of the change of operator if the change of operator does not entail the relocation of residents. The written notice shall be provided to the department of developmental disabilities and department of medicaid not later than ninety days before the effective date of the change of operator if the change of operator entails the relocation of residents.
The written notice shall include all of the following:
(1) The name of the exiting operator and, if any, the exiting operator's authorized agent;
(2) The name of the ICF/IID that is the subject of the change of operator;
(3) The exiting operator's seven-digit medicaid legacy number and ten-digit national provider identifier number for the ICF/IID that is the subject of the change of operator;
(4) The name of the entering operator;
(5) The effective date of the change of operator;
(6) The manner in which the entering operator becomes the ICF/IID's operator, including through sale, lease, merger, or other action;
(7) If the manner in which the entering operator becomes the ICF/IID's operator involves more than one step, a description of each step;
(8) Written authorization from the exiting operator or owner and entering operator for the department of medicaid to process a provider agreement for the entering operator;
(9) The names and addresses of the persons to whom the department of developmental disabilities and department of medicaid should send initial correspondence regarding the change of operator;
(10) The signature of the exiting operator's or owner's representative.
(B) An exiting operator or owner and entering operator immediately shall provide the department of developmental disabilities and department of medicaid notice of any changes to information included in a written notice of a change of operator that occur after that notice is provided to the department of developmental disabilities and department of medicaid. The notice of the changes shall be provided to the department of developmental disabilities and department of medicaid in accordance with the method specified in rules authorized by section 5124.53 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of medicaid may enter into a provider agreement with an entering operator that goes into effect at 12:01 a.m. on the effective date of the change of operator if all of the following requirements are met:
(A) The department receives a properly completed written notice required by section 5124.51 of the Revised Code on or before the date required by that section.
(B) The department receives both of the following in accordance with the method specified in rules authorized by section 5124.53 of the Revised Code and not later than ten days after the effective date of the change of operator:
(1) From the entering operator, a completed application for a provider agreement and all other forms and documents specified in rules authorized by section 5124.53 of the Revised Code;
(2) From the exiting operator or owner, all forms and documents specified in rules authorized by section 5124.53 of the Revised Code.
(C) The entering operator is eligible to enter into a provider agreement for the ICF/IID as provided in section 5124.06 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) The department of medicaid may enter into a provider agreement with an entering operator that goes into effect at 12:01 a.m. on the date determined under division (B) of this section if all of the following are the case:
(1) The department receives a properly completed written notice required by section 5124.51 of the Revised Code.
(2) The department receives, from the entering operator and in accordance with the method specified in rules authorized by section 5124.53 of the Revised Code, a completed application for a provider agreement and all other forms and documents specified in rules adopted under that section.
(3) The department receives, from the exiting operator or owner and in accordance with the method specified in rules authorized by section 5124.53 of the Revised Code, all forms and documents specified in rules adopted under that section.
(4) One or more of the following apply:
(a) The requirement of division (A)(1) of this section is met after the time required by section 5124.51 of the Revised Code;
(b) The requirement of division (A)(2) of this section is met more than ten days after the effective date of the change of operator;
(c) The requirement of division (A)(3) of this section is met more than ten days after the effective date of the change of operator.
(5) The entering operator is eligible to enter into a provider agreement for the ICF/IID as provided in section 5124.06 of the Revised Code.
(B) The department shall determine the date a provider agreement entered into under this section is to go into effect as follows:
(1) The effective date shall give the department sufficient time to process the change of operator and give the department sufficient time to assure no duplicate payments are made and make the withholding required by section 5124.521 of the Revised Code.
(2) The effective date shall be not earlier than the latest of the following:
(a) The effective date of the change of operator;
(b) The date that the entering operator complies with section 5124.51 of the Revised Code and division (A)(2) of this section;
(c) The date that the exiting operator or owner complies with section 5124.51 of the Revised Code and division (A)(3) of this section.
(3) The effective date shall be not later than the following after the later of the dates specified in division (B)(2) of this section:
(a) Forty-five days if the change of operator does not entail the relocation of residents;
(b) Ninety days if the change of operator entails the relocation of residents.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
A provider that enters into a provider agreement with the department of medicaid under section 5124.511 or 5124.512 of the Revised Code shall do all of the following:
(A) Comply with all applicable federal statutes and regulations;
(B) Comply with section 5124.07 of the Revised Code and all other applicable state statutes and rules;
(C) Comply with all the terms and conditions of the exiting operator's provider agreement, including all of the following:
(1) Any plan of correction;
(2) Compliance with health and safety standards;
(3) Compliance with the ownership and financial interest disclosure requirements of 42 C.F.R. 455.104, 455.105, and 1002.3;
(4) Compliance with the civil rights requirements of 45 C.F.R. parts 80, 84, and 90;
(5) Compliance with additional requirements imposed by the department;
(6) Any sanctions relating to remedies for violation of the provider agreement, including deficiencies, compliance periods, accountability periods, monetary penalties, notification for correction of contract violations, and history of deficiencies.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
In the case of a change of operator, the exiting operator shall be considered to be the operator of the ICF/IID for purposes of the medicaid program, including medicaid payments, until the effective date of the entering operator's provider agreement if the provider agreement is entered into under section 5124.511 or 5124.512 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of medicaid may enter into a provider agreement as provided in section 5124.07 of the Revised Code, rather than section 5124.511 or 5124.512 of the Revised Code, with an entering operator if the entering operator does not agree to a provider agreement that satisfies the requirements of division (C) of section 5124.513 of the Revised Code. The department may not enter into the provider agreement unless the department of health certifies the ICF/IID under Title XIX. The effective date of the provider agreement shall not precede any of the following:
(A) The date that the department of health certifies the ICF/IID;
(B) The effective date of the change of operator;
(C) The date the requirement of section 5124.51 of the Revised Code is satisfied.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The director of developmental disabilities may adopt rules under section 5124.03 of the Revised Code governing adjustments to the medicaid reimbursement rate for an ICF/IID that undergoes a change of operator. No rate adjustment resulting from a change of operator shall be effective before the effective date of the entering operator's provider agreement. This is the case regardless of whether the provider agreement is entered into under section 5124.511, section 5124.512, or, pursuant to section 5124.515, section 5124.07 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities' determination that a change of operator has or has not occurred for purposes of licensure under section 5123.19 of the Revised Code shall not affect either of the following:
(A) A determination by the department of developmental disabilities or department of medicaid of whether or when a change of operator occurs;
(B) The department of medicaid's determination of the effective date of an entering operator's provider agreement under section 5124.511, section 5124.512, or, pursuant to section 5124.515, section 5124.07 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) On receipt of a written notice under section 5124.50 of the Revised Code of a facility closure or voluntary termination, on receipt of a written notice under section 5124.51 of the Revised Code of a change of operator, or on the effective date of an involuntary termination, the department of developmental disabilities shall estimate the amount of any overpayments made under the medicaid program to the exiting operator, including overpayments the exiting operator disputes, and other actual and potential debts the exiting operator owes or may owe to the department and United States centers for medicare and medicaid services under the medicaid program, including a franchise permit fee.
(B) In estimating the exiting operator's other actual and potential debts to the department and the United States centers for medicare and medicaid services under the medicaid program, the department shall use a debt estimation methodology the director of developmental disabilities shall establish in rules authorized by section 5124.53 of the Revised Code. The methodology shall provide for estimating all of the following that the department determines are applicable:
(1) Refunds due the department under section 5124.41 of the Revised Code;
(2) Interest owed to the department and United States centers for medicare and medicaid services;
(3) Final civil monetary and other penalties for which all right of appeal has been exhausted;
(4) Money owed the department and United States centers for medicare and medicaid services from any outstanding final fiscal audit, including a final fiscal audit for the last fiscal year or portion thereof in which the exiting operator participated in the medicaid program;
(5) Other amounts the department determines are applicable.
(C) The department shall provide the exiting operator written notice of the department's estimate under division (A) of this section not later than thirty days after the department receives the notice under section 5124.50 of the Revised Code of the facility closure or voluntary termination; the department receives the notice under section 5124.51 of the Revised Code of the change of operator; or the effective date of the involuntary termination. The department's written notice shall include the basis for the estimate.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Except as provided in divisions (B), (C), and (D) of this section, the department of developmental disabilities may withhold from payment due an exiting operator under the medicaid program the total amount specified in the notice provided under division (C) of section 5124.52 of the Revised Code that the exiting operator owes or may owe to the department and United States centers for medicare and medicaid services under the medicaid program.
(B) In the case of a change of operator and subject to division (E) of this section, the following shall apply regarding a withholding under division (A) of this section if the exiting operator or entering operator or an affiliated operator executes a successor liability agreement meeting the requirements of division (F) of this section:
(1) If the exiting operator, entering operator, or affiliated operator assumes liability for the total, actual amount of debt the exiting operator owes the department and the United States centers for medicare and medicaid services under the medicaid program as determined under section 5124.525 of the Revised Code, the department shall not make the withholding.
(2) If the exiting operator, entering operator, or affiliated operator assumes liability for only the portion of the amount specified in division (B)(1) of this section that represents the franchise permit fee the exiting operator owes, the department shall withhold not more than the difference between the total amount specified in the notice provided under division (C) of section 5124.52 of the Revised Code and the amount for which the exiting operator, entering operator, or affiliated operator assumes liability.
(C) In the case of a voluntary termination or facility closure and subject to division (E) of this section, the following shall apply regarding a withholding under division (A) of this section if the exiting operator or an affiliated operator executes a successor liability agreement meeting the requirements of division (F) of this section:
(1) If the exiting operator or affiliated operator assumes liability for the total, actual amount of debt the exiting operator owes the department and the United States centers for medicare and medicaid services under the medicaid program as determined under section 5124.525 of the Revised Code, the department shall not make the withholding.
(2) If the exiting operator or affiliated operator assumes liability for only the portion of the amount specified in division (C)(1) of this section that represents the franchise permit fee the exiting operator owes, the department shall withhold not more than the difference between the total amount specified in the notice provided under division (C) of section 5124.52 of the Revised Code and the amount for which the exiting operator or affiliated operator assumes liability.
(D) In the case of an involuntary termination and subject to division (E) of this section, the following shall apply regarding a withholding under division (A) of this section if the exiting operator, the entering operator, or an affiliated operator executes a successor liability agreement meeting the requirements of division (F) of this section and the department approves the successor liability agreement:
(1) If the exiting operator, entering operator, or affiliated operator assumes liability for the total, actual amount of debt the exiting operator owes the department and the United States centers for medicare and medicaid services under the medicaid program as determined under section 5124.525 of the Revised Code, the department shall not make the withholding.
(2) If the exiting operator, entering operator, or affiliated operator assumes liability for only the portion of the amount specified in division (D)(1) of this section that represents the franchise permit fee the exiting operator owes, the department shall withhold not more than the difference between the total amount specified in the notice provided under division (C) of section 5124.52 of the Revised Code and the amount for which the exiting operator, entering operator, or affiliated operator assumes liability.
(E) For an exiting operator or affiliated operator to be eligible to enter into a successor liability agreement under division (B), (C), or (D) of this section, both of the following must apply:
(1) The exiting operator or affiliated operator must have one or more valid provider agreements, other than the provider agreement for the ICF/IID that is the subject of the involuntary termination, voluntary termination, facility closure, or change of operator;
(2) During the twelve-month period preceding either the effective date of the involuntary termination or the month in which the department receives the notice of the voluntary termination or facility closure under section 5124.50 of the Revised Code or the notice of the change of operator under section 5124.51 of the Revised Code, the average monthly medicaid payment made to the exiting operator or affiliated operator pursuant to the exiting operator's or affiliated operator's one or more provider agreements, other than the provider agreement for the ICF/IID that is the subject of the involuntary termination, voluntary termination, facility closure, or change of operator, must equal at least ninety per cent of the sum of the following:
(a) The average monthly medicaid payment made to the exiting operator pursuant to the exiting operator's provider agreement for the ICF/IID that is the subject of the involuntary termination, voluntary termination, facility closure, or change of operator;
(b) Whichever of the following apply:
(i) If the exiting operator or affiliated operator has assumed liability under one or more other successor liability agreements, the total amount for which the exiting operator or affiliated operator has assumed liability under the other successor liability agreements;
(ii) If the exiting operator or affiliated operator has not assumed liability under any other successor liability agreements, zero.
(F) A successor liability agreement executed under this section must comply with all of the following:
(1) It must provide for the operator who executes the successor liability agreement to assume liability for either of the following as specified in the agreement:
(a) The total, actual amount of debt the exiting operator owes the department and the United States centers for medicare and medicaid services under the medicaid program as determined under section 5124.525 of the Revised Code;
(b) The portion of the amount specified in division (F)(1)(a) of this section that represents the franchise permit fee the exiting operator owes.
(2) It may not require the operator who executes the successor liability agreement to furnish a surety bond.
(3) It must provide that the department, after determining under section 5124.525 of the Revised Code the actual amount of debt the exiting operator owes the department and United States centers for medicare and medicaid services under the medicaid program, may deduct the lesser of the following from medicaid payments made to the operator who executes the successor liability agreement:
(a) The total, actual amount of debt the exiting operator owes the department and the United States centers for medicare and medicaid services under the medicaid program as determined under section 5124.525 of the Revised Code;
(b) The amount for which the operator who executes the successor liability agreement assumes liability under the agreement.
(4) It must provide that the deductions authorized by division (F)(3) of this section are to be made for a number of months, not to exceed six, agreed to by the operator who executes the successor liability agreement and the department or, if the operator who executes the successor liability agreement and department cannot agree on a number of months that is less than six, a greater number of months determined by the attorney general pursuant to a claims collection process authorized by statute of this state.
(5) It must provide that, if the attorney general determines the number of months for which the deductions authorized by division (F)(3) of this section are to be made, the operator who executes the successor liability agreement shall pay, in addition to the amount collected pursuant to the attorney general's claims collection process, the part of the amount so collected that, if not for division (H) of this section, would be required by section 109.081 of the Revised Code to be paid into the attorney general claims fund.
(G) Execution of a successor liability agreement does not waive an exiting operator's right to contest the amount specified in the notice the department provides the exiting operator under division (C) of section 5124.52 of the Revised Code.
(H) Notwithstanding section 109.081 of the Revised Code, the entire amount that the attorney general, whether by employees or agents of the attorney general or by special counsel appointed pursuant to section 109.08 of the Revised Code, collects under a successor liability agreement, other than the additional amount the operator who executes the agreement is required by division (F)(5) of this section to pay, shall be paid to the department of developmental disabilities for deposit into the appropriate fund. The additional amount that the operator is required to pay shall be paid into the state treasury to the credit of the attorney general claims fund created under section 109.081 of the Revised Code.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) Except as provided in division (B) of this section, an exiting operator shall file with the department of developmental disabilities a cost report not later than ninety days after the last day the exiting operator's provider agreement is in effect. The cost report shall cover the period that begins with the day after the last day covered by the operator's most recent previous cost report filed under section 5124.10 or 5124.101 of the Revised Code and ends on the last day the exiting operator's provider agreement is in effect. The cost report shall include, as applicable, all of the following:
(1) The sale price of the ICF/IID;
(2) A final depreciation schedule that shows which assets are transferred to the buyer and which assets are not transferred to the buyer;
(3) Any other information the department requires.
(B) The department, at its sole discretion, may waive the requirement that an exiting operator file a cost report in accordance with division (A) of this section.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
If an exiting operator required by section 5124.522 of the Revised Code to file a cost report with the department of developmental disabilities fails to file the cost report in accordance with that section, all payments under the medicaid program for the period the cost report is required to cover are deemed overpayments until the date the department receives the properly completed cost report. The department may impose on the exiting operator a penalty of one hundred dollars for each calendar day the properly completed cost report is late.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities may not provide an exiting operator final payment under the medicaid program until the department receives all properly completed cost reports the exiting operator is required to file under sections 5124.10 and 5124.522 of the Revised Code.
Amended by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities shall determine the actual amount of debt an exiting operator owes the department and the United States centers for medicare and medicaid services under the medicaid program by completing all final fiscal audits not already completed and performing all other appropriate actions the department determines to be necessary. The department shall issue an initial debt summary report on this matter not later than sixty days after the date the exiting operator files the properly completed cost report required by section 5124.522 of the Revised Code with the department or, if the department waives the cost report requirement for the exiting operator, sixty days after the date the department waives the cost report requirement. The initial debt summary report becomes the final debt summary report thirty-one days after the department issues the initial debt summary report unless the exiting operator, or an affiliated operator who executes a successor liability agreement under section 5124.521 of the Revised Code, requests a review before that date.
The exiting operator, and an affiliated operator who executes a successor liability agreement under section 5124.521 of the Revised Code, may request a review to contest any of the department's findings included in the initial debt summary report. The request for the review must be submitted to the department not later than thirty days after the date the department issues the initial debt summary report. The department shall conduct the review on receipt of a timely request and issue a revised debt summary report. If the department has withheld money from payment due the exiting operator under division (A) of section 5124.521 of the Revised Code, the department shall issue the revised debt summary report not later than ninety days after the date the department receives the timely request for the review unless the department and exiting operator or affiliated operator agree to a later date. The exiting operator or affiliated operator may submit information to the department explaining what the operator contests before and during the review, including documentation of the amount of any debt the department owes the operator. The exiting operator or affiliated operator may submit additional information to the department not later than thirty days after the department issues the revised debt summary report. The revised debt summary report becomes the final debt summary report thirty-one days after the department issues the revised debt summary report unless the exiting operator or affiliated operator timely submits additional information to the department. If the exiting operator or affiliated operator timely submits additional information to the department, the department shall consider the additional information and issue a final debt summary report not later than sixty days after the department issues the revised debt summary report unless the department and exiting operator or affiliated operator agree to a later date.
Each debt summary report the department issues under this section shall include the department's findings and the amount of debt the department determines the exiting operator owes the department and United States centers for medicare and medicaid services under the medicaid program. The department shall explain its findings and determination in each debt summary report.
The exiting operator, and an affiliated operator who executes a successor liability agreement under section 5124.521 of the Revised Code, may request, in accordance with Chapter 119. of the Revised Code, an adjudication regarding a finding in a final debt summary report that pertains to an audit or alleged overpayment made under the medicaid program to the exiting operator. The adjudication shall be consolidated with any other uncompleted adjudication that concerns a matter addressed in the final debt summary report.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities shall release the actual amount withheld under division (A) of section 5124.521 of the Revised Code, less any amount the exiting operator owes the department and United States centers for medicare and medicaid services under the medicaid program, as follows:
(A) Unless the department issues the initial debt summary report required by section 5124.525 of the Revised Code not later than sixty days after the date the exiting operator files the properly completed cost report required by section 5124.522 of the Revised Code, sixty-one days after the date the exiting operator files the properly completed cost report;
(B) If the department issues the initial debt summary report required by section 5124.525 of the Revised Code not later than sixty days after the date the exiting operator files a properly completed cost report required by section 5124.522 of the Revised Code, not later than the following:
(1) Thirty days after the deadline for requesting an adjudication under section 5124.525 of the Revised Code regarding the final debt summary report if the exiting operator, and an affiliated operator who executes a successor liability agreement under section 5124.521 of the Revised Code, fail to request the adjudication on or before the deadline;
(2) Thirty days after the completion of an adjudication of the final debt summary report if the exiting operator, or an affiliated operator who executes a successor liability agreement under section 5124.521 of the Revised Code, requests the adjudication on or before the deadline for requesting the adjudication.
(C) Unless the department issues the initial debt summary report required by section 5124.525 of the Revised Code not later than sixty days after the date the department waives the cost report requirement of section 5124.522 of the Revised Code, sixty-one days after the date the department waives the cost report requirement;
(D) If the department issues the initial debt summary report required by section 5124.525 of the Revised Code not later than sixty days after the date the department waives the cost report requirement of section 5124.522 of the Revised Code, not later than the following:
(1) Thirty days after the deadline for requesting an adjudication under section 5124.525 of the Revised Code regarding the final debt summary report if the exiting operator, and an affiliated operator who executes a successor liability agreement under section 5124.521 of the Revised Code, fail to request the adjudication on or before the deadline;
(2) Thirty days after the completion of an adjudication of the final debt summary report if the exiting operator, or an affiliated operator who executes a successor liability agreement under section 5124.521 of the Revised Code, requests the adjudication on or before the deadline for requesting the adjudication.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The department of developmental disabilities, at its sole discretion, may release the amount withheld under division (A) of section 5124.521 of the Revised Code if the exiting operator submits to the department written notice of a postponement of a change of operator, facility closure, or voluntary termination and the transactions leading to the change of operator, facility closure, or voluntary termination are postponed for at least thirty days but less than ninety days after the date originally proposed for the change of operator, facility closure, or voluntary termination as reported in the written notice required by section 5124.50 or 5124.51 of the Revised Code. The department shall release the amount withheld if the exiting operator submits to the department written notice of a cancellation or postponement of a change of operator, facility closure, or voluntary termination and the transactions leading to the change of operator, facility closure, or voluntary termination are canceled or postponed for more than ninety days after the date originally proposed for the change of operator, facility closure, or voluntary termination as reported in the written notice required by section 5124.50 or 5124.51 of the Revised Code. A written notice shall be provided to the department in accordance with the method specified in rules authorized by section 5124.53 of the Revised Code.
After the department receives a written notice regarding a cancellation or postponement of a facility closure or voluntary termination, the exiting operator or owner shall provide new written notice to the department under section 5124.50 of the Revised Code regarding any transactions leading to a facility closure or voluntary termination at a future time. After the department receives a written notice regarding a cancellation or postponement of a change of operator, the exiting operator or owner and entering operator shall provide new written notice to the department under section 5124.51 of the Revised Code regarding any transactions leading to a change of operator at a future time.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
(A) All amounts withheld under section 5124.521 of the Revised Code from payment due an exiting operator under the medicaid program shall be deposited into the medicaid payment withholding fund created by the controlling board pursuant to section 131.35 of the Revised Code. Money in the fund shall be used as follows:
(1) To pay an exiting operator when a withholding is released to the exiting operator under section 5124.526 or 5124.527 of the Revised Code;
(2) To pay the department of medicaid or department of developmental disabilities, and United States centers for medicare and medicaid services, the amount an exiting operator owes the department of medicaid or department of developmental disabilities and United States centers under the medicaid program.
(B) Amounts paid from the medicaid payment withholding fund pursuant to division (A)(2) of this section shall be deposited into the appropriate fund.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
The director of developmental disabilities shall adopt rules under section 5124.03 of the Revised Code to implement sections 5124.50 to 5124.53 of the Revised Code. The rules shall specify all of the following:
(A) The method by which written notices to the department required by sections 5124.50 to 5124.53 of the Revised Code are to be provided;
(B) The forms and documents that are to be provided to the department under sections 5124.511 and 5124.512 of the Revised Code, which shall include, in the case of such forms and documents provided by entering operators, all the fully executed leases, management agreements, merger agreements and supporting documents, and fully executed sales contracts and any other supporting documents culminating in the change of operator;
(C) The method by which the forms and documents identified in division (B) of this section are to be provided to the department.
Amended by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
For the purpose of increasing the number of slots available for home and community-based services and subject to sections 5124.63 and 5124.64 of the Revised Code, the operator of an ICF/IID may convert some or all of the beds in the ICF/IID from providing ICF/IID services to providing home and community-based services if all of the following requirements are met:
(1) The operator provides the directors of health and developmental disabilities at least ninety days' notice of the operator's intent to make the conversion.
(2) The operator complies with the requirements of sections 5124.50 to 5124.53 of the Revised Code regarding a voluntary termination if those requirements are applicable.
(3) If the operator intends to convert all of the ICF/IID's beds, the operator notifies each of the ICF/IID's residents that the ICF/IID is to cease providing ICF/IID services and inform each resident that the resident may do either of the following:
(a) Continue to receive ICF/IID services by transferring to another ICF/IID that is willing and able to accept the resident if the resident continues to qualify for ICF/IID services;
(b) Begin to receive home and community-based services instead of ICF/IID services from any provider of home and community-based services that is willing and able to provide the services to the resident if the resident is eligible for the services and a slot for the services is available to the resident.
(4) If the operator intends to convert some but not all of the ICF/IID's beds, the operator notifies each of the ICF/IID's residents that the ICF/IID is to convert some of its beds from providing ICF/IID services to providing home and community-based services and inform each resident that the resident may do either of the following:
(a) Continue to receive ICF/IID services from any ICF/IID that is willing and able to provide the services to the resident if the resident continues to qualify for ICF/IID services;
(b) Begin to receive home and community-based services instead of ICF/IID services from any provider of home and community-based services that is willing and able to provide the services to the resident if the resident is eligible for the services and a slot for the services is available to the resident.
(5) The operator meets the requirements for providing home and community-based services, including the following:
(a) Such requirements applicable to a residential facility if the operator maintains the facility's license as a residential facility;
(b) Such requirements applicable to a facility that is not licensed as a residential facility if the operator surrenders the facility's license as a residential facility under section 5123.19 of the Revised Code.
(6) The director of developmental disabilities approves the conversion.
(B) A decision by the director of developmental disabilities to approve or refuse to approve a proposed conversion of beds is final. In making a decision, the director shall consider all of the following:
(1) The fiscal impact on the ICF/IID if some but not all of the beds are converted;
(2) The fiscal impact on the medicaid program;
(3) The availability of home and community-based services.
(C) The notice provided to the directors under division (A)(1) of this section shall specify whether some or all of the ICF/IID's beds are to be converted. If some but not all of the beds are to be converted, the notice shall specify how many of the ICF/IID's beds are to be converted and how many of the beds are to continue to provide ICF/IID services. The notice to the director of developmental disabilities shall specify whether the operator wishes to surrender the ICF/IID's license as a residential facility under section 5123.19 of the Revised Code.
(1) If the director of developmental disabilities approves a conversion under division (B) of this section, the director of health shall do the following:
(a) Terminate the ICF/IID's medicaid certification if the notice specifies that all of the ICF/IID's beds are to be converted;
(b) Reduce the ICF/IID's medicaid-certified capacity by the number of beds being converted if the notice specifies that some but not all of the beds are to be converted.
(2) The director of health shall notify the medicaid director of the termination or reduction. On receipt of the notice, the medicaid director shall do the following:
(a) Terminate the operator's medicaid provider agreement that authorizes the operator to provide ICF/IID services at the ICF/IID if the ICF/IID's certification was terminated;
(b) Amend the operator's medicaid provider agreement to reflect the ICF/IID's reduced medicaid-certified capacity if the ICF/IID's medicaid-certified capacity is reduced.
(3) In the case of action taken under division (D)(2)(a) of this section, the operator is not entitled to notice or a hearing under Chapter 119. of the Revised Code before the medicaid director terminates the medicaid provider agreement.
Renumbered from § 5111.874 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 9/10/2012.
Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Amended by 128th General AssemblyFile No.33, HB 398, §1, eff. 8/31/2010.
Amended by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 7/17/2009.
Amended by 128th General Assemblych.9, SB 79, §1, eff. 10/6/2009.
Effective Date: 2008 HB562 06-24-2008
(A) For the purpose of increasing the number of slots available for home and community-based services and subject to sections 5124.63 and 5124.64 of the Revised Code, a person who acquires, through a request for proposals issued by the director of developmental disabilities, an ICF/IID for which a residential facility license was previously surrendered or revoked may convert some or all of the ICF/IID's beds from providing ICF/IID services to providing home and community-based services if all of the following requirements are met:
(1) The person provides the directors of health and developmental disabilities and medicaid director at least ninety days' notice of the person's intent to make the conversion.
(2) The person complies with the requirements of sections 5124.50 to 5124.53 of the Revised Code regarding a voluntary termination if those requirements are applicable.
(3) If the person intends to convert all of the ICF/IID's beds, the person notifies each of the ICF/IID's residents that the ICF/IID is to cease providing ICF/IID services and informs each resident that the resident may do either of the following:
(a) Continue to receive ICF/IID services by transferring to another ICF/IID willing and able to accept the resident if the resident continues to qualify for ICF/IID services;
(b) Begin to receive home and community-based services instead of ICF/IID services from any provider of home and community-based services that is willing and able to provide the services to the resident if the resident is eligible for the services and a slot for the services is available to the resident.
(4) If the person intends to convert some but not all of the ICF/IID's beds, the person notifies each of the ICF/IID's residents that the ICF/IID is to convert some of its beds from providing ICF/IID services to providing home and community-based services and inform each resident that the resident may do either of the following:
(a) Continue to receive ICF/IID services from any that is willing and able to provide the services to the resident if the resident continues to qualify for ICF/IID services;
(b) Begin to receive home and community-based services instead of ICF/IID services from any provider of home and community-based services that is willing and able to provide the services to the resident if the resident is eligible for the services and a slot for the services is available to the resident.
(5) The person meets the requirements for providing home and community-based services at a residential facility.
(B) The notice provided to the directors under division (A)(1) of this section shall specify whether some or all of the ICF/IID's beds are to be converted. If some but not all of the beds are to be converted, the notice shall specify how many of the ICF/IID's beds are to be converted and how many of the beds are to continue to provide ICF/IID services.
(C) On receipt of a notice under division (A)(1) of this section, the director of health shall do the following:
(1) Terminate the ICF/IID's medicaid certification if the notice specifies that all of the facility's beds are to be converted;
(2) Reduce the ICF/IID's medicaid-certified capacity by the number of beds being converted if the notice specifies that some but not all of the beds are to be converted.
(D) The director of health shall notify the medicaid director of the termination or reduction under division (C) of this section. On receipt of the director of health's notice, the medicaid director shall do the following:
(1) Terminate the person's medicaid provider agreement that authorizes the person to provide ICF/IID services at the ICF/IID if the ICF/IID's medicaid certification was terminated;
(2) Amend the person's medicaid provider agreement to reflect the ICF/IID's reduced medicaid-certified capacity if the ICF/IID's medicaid-certified capacity is reduced.
The person is not entitled to notice or a hearing under Chapter 119. of the Revised Code before the medicaid director terminates or amends the medicaid provider agreement.
Renumbered from § 5111.875 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 128th General AssemblyFile No.33, HB 398, §1, eff. 8/31/2010.
Amended by 128th General AssemblyFile No.9, HB 1, §101.01, eff. 7/17/2009.
Amended by 128th General Assemblych.9, SB 79, §1, eff. 10/6/2009.
Effective Date: 2008 HB562 06-24-2008
Subject to section 5124.63 of the Revised Code, the director of developmental disabilities may request that the medicaid director seek the approval of the United States secretary of health and human services to increase the number of slots available for home and community-based services by a number not exceeding the number of beds that were part of the licensed capacity of a residential facility that had its license revoked or surrendered under section 5123.19 of the Revised Code if the residential facility was an ICF/IID at the time of the license revocation or surrender. The revocation or surrender may have occurred before, or may occur on or after, June 24, 2008. The request may include beds the director of developmental disabilities removed from such a residential facility's licensed capacity before transferring ownership or operation of the residential facility pursuant to a request for proposals.
Renumbered from § 5111.876 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 128th General Assemblych.9, SB 79, §1, eff. 10/6/2009.
Effective Date: 2008 HB562 06-24-2008
The medicaid director may seek approval from the United States secretary of health and human services for not more than a total of six hundred slots for home and community-based services for the purposes of sections 5124.60, 5124.61, and 5124.62 of the Revised Code.
Renumbered from § 5111.877 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 9/10/2012.
Amended by 129th General AssemblyFile No.28, HB 153, §101.01, eff. 9/29/2011.
Effective Date: 2008 HB562 06-24-2008
Not more than a total of six hundred beds may be converted from providing ICF/IID services to providing home and community-based services under sections 5124.60 and 5124.61 of the Revised Code.
Renumbered from § 5111.878 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Amended by 129th General AssemblyFile No.127, HB 487, §101.01, eff. 9/10/2012.
Effective Date: 2008 HB562 06-24-2008
No person or government entity may reconvert a bed to be used for ICF/IID services if the bed was converted to use for home and community-based services under section 5124.60 or 5124.61 of the Revised Code. This prohibition applies regardless of either of the following:
(A) The bed is part of the licensed capacity of a residential facility.
(B) The bed has been sold, leased, or otherwise transferred to another person or government entity.
Renumbered from § 5111.879 by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Effective Date: 2008 HB562 06-24-2008
(A) The department of developmental disabilities shall strive to achieve, not later than July 1, 2018, the following statewide reductions in ICF/IID beds:
(1) At least five hundred and not more than six hundred beds in ICFs/IID that, before becoming downsized ICFs/IID, have sixteen or more beds;
(2) At least five hundred and not more than six hundred beds in ICFs/IID with any number of beds that convert some or all of their beds from providing ICF/IID services to providing home and community-based services pursuant to section 5124.60 or 5124.61 of the Revised Code.
(B) In its efforts to achieve the reductions under division (A) of this section, the department shall collaborate with the Ohio association of county boards serving people with developmental disabilities, the Ohio provider resource association, the Ohio centers for intellectual disabilities formed by the Ohio health care association, and the values and faith alliance. The collaboration efforts may include the following:
(1) Identifying ICFs/IID that may reduce the number of their beds to help achieve the reductions under division (A) of this section;
(2) Encouraging ICF/IID providers to reduce the number of their ICFs/IID's beds;
(3) Establishing interim time frames for making progress in achieving the reductions;
(4) Creating incentives for, and removing impediments to, the reductions;
(5) In the case of ICF/IID beds that are converted to providing home and community-based services, developing a mechanism to compensate providers for beds that permanently cease to provide ICF/IID services.
(C) The department shall meet not less than twice each year with the organizations specified in division (B) of this section to do all of the following:
(1) Review the progress being made in achieving the reductions under division (A) of this section;
(2) Prepare written reports on the progress;
(3) Identify additional measures needed to achieve the reductions.
Repealed by 130th General Assembly File No. 25, HB 59, §125.11.03, eff. 7/1/2018.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.
Whoever violates section 5124.102 or division (E) of section 5124.08 of the Revised Code shall be fined not less than five hundred dollars nor more than one thousand dollars for the first offense and not less than one thousand dollars nor more than five thousand dollars for each subsequent offense.
Fines paid under this section shall be deposited in the state treasury to the credit of the general revenue fund.
Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.