5124.192 Case-mix scores.

(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.

(B)

(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.

History. Added by 130th General Assembly File No. 25, HB 59, §101.01, eff. 9/29/2013.