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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 5123-7 | Personnel

 
 
 
Rule
Rule 5123-7-01 | Intermediate care facilities for individuals with intellectual disabilities - definitions.
 

For the purposes of rules in Chapters 5123-7 and 5123:2-7 of the Administrative Code, the following definitions shall apply unless otherwise provided:

(A) "Allowable costs" are those costs incurred for certified beds in an ICFIID as determined by the department to be reasonable, as defined in paragraph (K) of this rule, and do not include recoupments, fines, penalties, or interest paid in accordance with sections 5124.39, 5124.41, 5124.42, 5124.523, and 5124.99 of the Revised Code. Unless otherwise enumerated in Chapter 5123-7 or 5123:2-7 of the Administrative Code, allowable costs are also determined in accordance with the following reference material, in the following priority:

(1) 42 C.F.R. Chapter IV, as in effect on the effective date of this rule;

(2) The centers for medicare and medicaid services provider reimbursement manual (publications 15-1 and 15-2, available at https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals.html); and

(3) Generally accepted accounting principles in accordance with standards prescribed by the "American Institute of Certified Public Accountants" (available at https://www.aicpa.org).

(B) "Date of licensure," for an ICFIID originally licensed as a nursing home under Chapter 3721. of the Revised Code, means the date specific beds were originally licensed as nursing home beds under that chapter, regardless of whether they were subsequently licensed as residential facility beds. For a facility originally licensed as a residential facility, "date of licensure" means the date specific beds were originally licensed as residential facility beds under that section.

(1) If nursing home beds licensed under Chapter 3721. of the Revised Code or residential facility beds licensed under section 5123.19 of the Revised Code were not required by law to be licensed when they were originally used to provide nursing home or residential facility services, "date of licensure" means the date the beds first were used to provide nursing home or residential facility services, regardless of the date the present provider obtained licensure.

(2) If a facility adds nursing home or residential facility beds or in the case of an ICFIID with more than eight beds or a nursing facility, it extensively renovates the facility after its original date of licensure, it will have a different date of licensure for the additional beds or for the extensively renovated facility, unless, in the case of the addition of beds, the beds are added in a space that was constructed at the same time as the previously licensed beds but was not licensed under Chapter 3721. or section 5123.19 of the Revised Code at that time. The licensure date for additional beds or facilities which extensively renovate shall be the date the beds are placed into service.

(C) "Department" means the Ohio department of developmental disabilities.

(D) "Fiscal year" means the fiscal year of this state, as specified in section 9.34 of the Revised Code.

(E) "Inpatient days" means all days during which a resident, regardless of payment source, occupies a bed in an ICFIID that is included in the ICFIID's certified capacity under Title XIX of the Social Security Act, 49 stat. 620 , 42 U.S.C.A. 301, as in effect on the effective date of this rule. Bed-hold days determined in accordance with rule 5123:2-7-08 of the Administrative Code are considered inpatient days proportionate to the percentage of the ICFIID's per resident per day rate paid for those days.

(F) "Intermediate care facility for individuals with intellectual disabilities" (or "ICFIID") has the same meaning as in section 5124.01 of the Revised Code.

(G) "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 an ICFIID.

(H) "Provider" means a person or government entity that operates an ICFIID under a provider agreement.

(I) "Provider agreement" means a contract between the Ohio department of medicaid and an operator of an ICFIID for the provision of ICFIID services under the medicaid program. The signature of the operator or the operator's authorized agent binds the operator to the terms of the agreement.

(J) "Qualified intellectual disability professional" has the same meaning as in 42 C.F.R. 483.430, as in effect on the effective date of this rule.

(K) "Reasonable" means that a cost is an actual cost that is appropriate and helpful to develop and maintain the operation of an ICFIID and resident activities, including normal standby costs, and that does not exceed what a prudent buyer pays for a given item or service. Reasonable costs may vary from provider to provider and from time to time for the same provider.

(L) "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, the 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 ICFIID from outside organizations and are not a basic element of resident care ordinarily furnished directly to residents by the ICFIID; and

(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.

(M) "Relative of an owner" means a person who is related to an owner of an ICFIID 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; or

(7) Foster parent, foster child, foster brother, or foster sister.

(N) "Representative" means a person acting on behalf of an individual who is applying for or receiving medicaid. A representative may be a family member, guardian, attorney, hospital social worker, ICFIID social worker, or any other person chosen to act on the individual's behalf.

(O) "State survey agency" means the agency that inspects long-term care facilities for the purposes of survey and certification. The state survey agency in Ohio is the Ohio department of health.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.01, 5124.03
Five Year Review Date: 7/8/2023
Prior Effective Dates: 1/10/2013
Rule 5123-7-02 | Intermediate care facilities for individuals with intellectual disabilities - provider agreement and other essential requirements.
 

(A) Purpose

This rule sets forth requirements for an intermediate care facility for individuals with intellectual disabilities (ICFIID) to be eligible for initial and continued participation in the Ohio medicaid program and to receive payment for ICFIID services to eligible residents.

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Certification" means the process by which the Ohio department of health certifies its findings to the federal centers for medicare and medicaid services or the Ohio department of medicaid with respect to a facility's compliance with health and safety requirements of divisions (a), (b), (c), and (d) of section 1919 of the Social Security Act, 42 U.S.C. 1396r (1999).

(2) "Certified beds" means beds that are counted in a facility that meets medicaid standards. A count of facility beds may differ depending on whether the count is used for certification, licensure, eligibility for medicaid payment formulas, eligibility for waivers, or other purposes.

(3) "Change of operator" has the same meaning as in section 5124.01 of the Revised Code.

(4) "Facility closure" has the same meaning as in section 5124.01 of the Revised Code.

(5) "Operator" means the individual, partnership, association, trust, corporation, or other legal entity that operates an ICFIID.

(6) "Residential respite" has the same meaning as in rule 5123-9-34 of the Administrative Code.

(7) "Voluntary termination" has the same meaning as in section 5124.01 of the Revised Code.

(C) Eligibility for participation

(1) To participate in the Ohio medicaid program an operator shall:

(a) Operate a residential facility licensed by the department in accordance with section 5123.19 of the Revised Code and rules adopted to implement that section.

(b) Operate a facility certified by the Ohio department of health as being in compliance with applicable federal regulations for medicaid participation as an ICFIID with a minimum of four certified beds. A facility's certification as an ICFIID by the Ohio department of health governs the types of services the facility may provide.

(c) Hold a medicaid provider agreement with the Ohio department of medicaid to operate the ICFIID.

(2) An operator shall:

(a) Execute the provider agreement in the format provided by the Ohio department of medicaid.

(b) Apply for and maintain a valid license issued by the department.

(c) Comply with the provider agreement and all applicable federal, state, and local laws and rules.

(d) Open all records relating to the costs of its services for inspection and audit by the department and the Ohio department of medicaid.

(e) Supply to the department and the Ohio department of medicaid such information as the department or the Ohio department of medicaid requires concerning services to individuals who have applied for or been determined to be eligible for medicaid.

(f) Permit access to the ICFIID and its records for inspection by the department, the Ohio department of medicaid, the Ohio department of health, the county department of job and family services, and any other state or local government entity having authority to inspect, to the extent of that entity's authority.

(g) In the case of a change of operator, adhere to the following procedures:

(i) The exiting operator or owner and entering operator must provide a written notice to the department and the Ohio department of medicaid, as provided in section 5124.51 of the Revised Code, at least forty-five calendar days prior to the effective date of any actions that constitute a change of operator, but at least ninety calendar days prior to the effective date if residents are to be relocated. An exiting operator that does not give proper notice is subject to the penalties specified in section 5124.42 of the Revised Code.

(ii) The entering operator must submit documentation of any transaction (e.g., sales agreement, contract, or lease) as requested by the department or the Ohio department of medicaid to determine whether a change of operator has occurred.

(iii) The entering operator shall submit an application for participation in the medicaid program and a written statement of intent to abide by rules of the department and the Ohio department of medicaid, the provisions of the assigned provider agreement, and any centers for medicare and medicaid services "Statement of Deficiencies and Plan of Correction" forms (CMS-2567, February 1999) submitted by the exiting operator.

(iv) An entering operator is subject to the same survey findings as the exiting operator unless the entering operator does not accept assignment of the exiting operator's provider agreement. Refusal to accept assignment results in termination of certification on the last day of the exiting operator's participation in medicaid. An entering operator who refuses assignment may reapply for medicaid participation and must undergo a complete initial certification survey by the Ohio department of health. There may be gaps in medicaid coverage at the facility.

(h) Comply with Title VI of the Civil Rights Act, 42 U.S.C. 2000d (1964), Title VII of the Civil Rights Act, 42 U.S.C. 2000e (1991), and the Americans with Disabilities Act of 1990, 42 U.S.C. 12101 (2008), and shall not discriminate against any resident on the basis of race, color, age, sex, gender, sexual orientation, creed, national origin, ancestry, religion, or disability.

(i) Provide notice to the department within five calendar days of any bankruptcy or receivership pertaining to the provider. All requests shall be in writing and shall be mailed to "Ohio Department of Developmental Disabilities, Division of Medicaid Development and Administration, 30 East Broad Street, 13th Floor, Columbus, Ohio 43215-3414."

(j) Provide the department, the Ohio department of medicaid, the resident or guardian (as applicable), and anyone designated by the resident or guardian written notice at least ninety calendar days prior to a facility closure or voluntary termination from the medicaid program in accordance with section 5124.50 of the Revised Code. An operator that does not issue the proper notice is subject to the penalties specified in section 5124.42 of the Revised Code.

(3) An operator shall not:

(a) Charge, to an individual or applicant who is eligible for medicaid:

(i) A fee for the application process;

(ii) An admission fee; or

(iii) An advance deposit.

(b) Directly bill its residents for or directly pass through to its residents the franchise permit fee.

(c) Require a third party to accept personal responsibility for paying the ICFIID charges out of his or her own funds. An operator, however, may require a representative who has legal access to an individual's income or resources available to pay for ICFIID services to sign a contract, without incurring personal financial liability, to provide payment from the individual's income or resources if the individual's medicaid application is denied and if the individual's cost of care is not being paid by medicare or another third-party payor. A third-party guarantee is not the same as a third-party payor (i.e., an insurance company), and this provision does not preclude the operator from obtaining information about medicare and medicaid eligibility or the availability of private insurance. The prohibition against third-party guarantees applies to all residents and prospective residents of an ICFIID regardless of payment source. This provision does not prohibit a third party from voluntarily making payment on behalf of an individual.

(D) Effective dates of provider agreements

(1) Effective dates of initial provider agreements generally are assigned by the Ohio department of health on the basis of findings of compliance or substantial compliance with standards of certification.

(2) If a provider agreement is involuntarily terminated by the centers for medicare and medicaid services as the result of a look behind survey, re-entry into the medicaid program requires satisfaction of the reasonable assurance period as set forth in the "Medicaid State Operations Manual," chapter 2, section 2016F (October 17, 2018).

(E) Conditional provider agreements and cancellation clauses

(1) If the Ohio department of health determines that an ICFIID is in substantial compliance with medicaid standards but has deficiencies that must be corrected, the Ohio department of medicaid may execute a conditional provider agreement for a term of up to twelve full calendar months, subject to an automatic cancellation clause.

(2) The ICFIID must correct deficiencies within sixty calendar days following the scheduled date of correction as established by the Ohio department of health.

(3) If deficiencies are corrected before the cancellation date, the Ohio department of health may rescind the cancellation notice, and shall notify the department and the Ohio department of medicaid in writing of its decision.

(4) If deficiencies are not corrected before the cancellation date, the Ohio department of health may propose termination of the provider agreement.

(5) If deficiencies are not corrected, the Ohio department of medicaid may cancel the provider agreement in accordance with section 5164.38 of the Revised Code, unless the Ohio department of health:

(a) Finds that all required corrections have been made and notifies the department and the Ohio department of medicaid; or

(b) Determines that substantial progress has been made in carrying out a plan of correction that has been submitted to and accepted by the Ohio department of health.

(F) Termination, suspension, denial, or non-renewal of provider agreement

(1) At the request of the department or upon its own initiative, the Ohio department of medicaid may terminate, suspend, or not enter into the provider agreement upon thirty calendar days written notice to the provider for a violation of Chapter 5123., 5124., or 5160. of the Revised Code or rules adopted pursuant to those chapters and if applicable, subject to Chapter 119. of the Revised Code.

(2) In accordance with section 5164.33 of the Revised Code, a provider agreement may be terminated, suspended, denied, or not revalidated if the Ohio department of medicaid determines such an agreement is not in the best interests of the state or medicaid recipients.

(3) The Ohio department of medicaid shall terminate, deny, or not revalidate a provider agreement when any of the situations set forth in division (E) of section 5164.38 of the Revised Code occur.

(G) Waiver of licensed capacity

(1) To accommodate persons in emergency need of ICFIID services, the department may issue an operator a waiver of licensed capacity. A waiver of licensed capacity is time-limited and temporarily permits the operator to exceed the maximum number of licensed beds.

(2) A waiver of licensed capacity may be made specifically in order to provide residential respite as a prior-authorized service to a person enrolled in a home and community-based services waiver. Beds designated for residential respite for persons enrolled in home and community-based services waivers shall not be included in the provider agreement.

(H) Beds subject to certification survey

(1) All beds in a medicaid-participating ICFIID that are not designated for residential respite for persons enrolled in home and community-based services waivers shall be surveyed to determine compliance with the applicable certification standards.

(2) If the beds are certifiable, they shall be included in the provider agreement.

(3) Beds authorized through a waiver of licensed capacity in accordance with paragraph (G)(1) of this rule that are used to provide ICFIID services shall be included in the provider agreement.

(4) The only other basis for allowing non-participation of a portion of an Ohio ICFIID is certification of noncompliance by the Ohio department of health.

(I) Requirements for out-of-state providers of ICFIID services

To participate in the Ohio medicaid program and receive payment for ICFIID services to eligible Ohio residents, an operator of a facility located outside Ohio shall:

(1) Hold a valid state-required license, registration, or equivalent from the respective state that specifies the level of care the facility is qualified to provide;

(2) Hold a medicaid provider agreement from the respective state as an ICFIID provider type;

(3) Hold a medicaid provider agreement with the Ohio department of medicaid; and

(4) Obtain resident-specific and date-specific prior authorization in accordance with rules 5160-1-11 and 5160-1-31 of the Administrative Code.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03
Five Year Review Date: 12/16/2024
Rule 5123-7-04 | Intermediate care facilities for individuals with intellectual disabilities - payment during the Ohio department of medicaid administrative appeals process for termination of a provider agreement.
 

(A) Purpose

This rule clarifies conditions under which payment may be made to an intermediate care facility for individuals with intellectual disabilities (ICFIID) during proposed termination and upon termination of the ICFIID's provider agreement by the Ohio department of medicaid.

(B) Payment during the appeals process

When the Ohio department of medicaid is required to provide an adjudicatory hearing pursuant to Chapter 119. of the Revised Code, payment shall continue for medicaid-covered services provided to eligible residents during the appeal of and the proposed termination of an ICFIID's provider agreement. Payment shall not be made under this provision for services rendered on or after the effective date of the issuance of a final order of adjudication pursuant to Chapter 119. of the Revised Code, except as provided in paragraph (C)(1) of this rule.

(C) Payment following termination of provider agreement

(1) Payment may be provided up to thirty calendar days following the effective date of termination of an ICFIID's provider agreement or after an administrative hearing decision that upholds the termination action. Payment will be available if both of the following conditions are met:

(a) Payment is for residents admitted to the ICFIID before the effective date of termination; and

(b) The ICFIID cooperates with federal, state, and local entities in the effort to transfer residents to other facilities or community programs that can meet the residents' needs.

(2) When the Ohio department of medicaid acts under instructions from the United States department of health and human services, payment ends on the termination date specified by that agency.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03
Five Year Review Date: 12/16/2024
Prior Effective Dates: 1/10/2013
Rule 5123-7-05 | Intermediate care facilities for individuals with intellectual disabilities - payment during the Ohio department of health administrative appeals process for termination or non-renewal of medicaid certification.
 

(A) Purpose

This rule clarifies conditions under which payment may be made to an intermediate care facility for individuals with intellectual disabilities (ICFIID) during proposed termination or non-renewal and upon termination or non-renewal of the ICFIID's medicaid certification by the Ohio department of health.

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Effective date of termination" means the date set by the Ohio department of health or the United States department of health and human services for the termination of medicaid certification.

(2) "Informal reconsideration" is the process by which an ICFIID may refute in writing, prior to the termination or non-renewal of medicaid certification, the Ohio department of health's findings on which the termination or non-renewal is based. The ICFIID must receive a written response to the informal reconsideration request which either affirms or reverses the survey decisions. Informal reconsideration is a process independent of the formal appeal. An ICFIID may or may not choose to utilize informal reconsideration.

(C) Informal reconsideration

In addition to or in conjunction with the appeals process, an ICFIID may request informal reconsideration. If informal reconsideration results in an affirmation of the original survey findings, the appeals process moves forward to the administrative hearing if one was requested. If informal reconsideration results in a reversal of the original survey findings, the Ohio department of health's termination or non-renewal action, based on those original findings, is dismissed.

(D) Payment during the appeals process

(1) During the appeals process provided by the Ohio department of health in accordance with rule 3701-63-01 of the Administrative Code for the proposed termination or non-renewal of medicaid certification, payment under regulations for covered services provided to eligible residents shall continue through the earlier of:

(a) The date of issuance of a final order of adjudication that upholds the Ohio department of health's termination or non-renewal action; or

(b) The one hundred twentieth calendar day after the effective date of termination of the ICFIID's provider agreement.

(2) Payment may be provided up to an additional thirty calendar days following either the cessation of payment on the one hundred twentieth calendar day post termination or non-renewal; or after the issuance of an adjudication order that upholds the termination or non-renewal action. Payment will be available if both of the following conditions are met:

(a) Payment is for residents admitted to the ICFIID before the effective date of termination or non-renewal; and

(b) The ICFIID cooperates with federal, state, and local entities in the effort to transfer residents to other facilities or community programs that can meet the residents' needs.

(E) Payment following termination of medicaid certification

(1) When the Ohio department of medicaid acts under instructions from the United States department of health and human services, payment ends on the termination date specified by that agency.

(2) When the Ohio department of health certifies that there is jeopardy to residents' health and safety by issuing an order under Chapter 5165. of the Revised Code, or when it fails to certify that there is no jeopardy, payment will end on the effective date of termination.

(F) Termination of provider agreement

When an ICFIID's medicaid certification is terminated or not renewed, the Ohio department of medicaid shall terminate the ICFIID's provider agreement.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03
Five Year Review Date: 12/16/2024
Prior Effective Dates: 1/10/2013
Rule 5123-7-09 | Intermediate care facilities for individuals with intellectual disabilities - personal needs allowance accounts.
 

(A) Purpose

This rule establishes requirements and procedures regarding personal needs allowance accounts of residents of an intermediate care facility for individuals with intellectual disabilities (ICFIID).

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Patient liability" means an individual's financial obligation toward the medicaid cost of care.

(2) "Personal needs allowance" means a required deduction in the computation of patient liability for needs of a resident of an ICFIID.

(3) "Personal needs allowance account" means an account or petty cash fund that holds the money of a resident of an ICFIID and is managed for the resident by the ICFIID.

(C) Management of resident funds

(1) An ICFIID shall allow residents to manage their financial affairs and teach them to do so to the extent of their capabilities in accordance with 42 C.F.R. 483.420, as in effect on the effective date of this rule.

(2) An ICFIID shall hold, safeguard, manage, account for, and convey a resident's funds in accordance with rule 5123:2-2-07 of the Administrative Code.

(D) Personal needs allowance account

(1) A medicaid-eligible resident of an ICFIID may retain a personal needs allowance account in the amount set forth in section 5163.33 of the Revised Code.

(2) A personal needs allowance account is the exclusive property of the resident, who may use the funds as he or she chooses in any lawful manner.

(3) An ICFIID shall not require a resident to deposit his or her personal needs allowance funds with the ICFIID; a resident wishing to do so shall submit a request to the ICFIID in writing.

(4) An ICFIID shall explain both verbally and in writing to a resident or the resident's representative, as applicable, that personal needs allowance funds are for the resident to use as he or she chooses. If a resident's representative is the payee for the resident's personal needs allowance account, the resident's representative shall be responsible for ensuring that the funds are used to meet the personal needs of the resident.

(E) Notification of certain balances and transactions that may affect medicaid eligibility

(1) When the funds in a personal needs allowance account of a medicaid-eligible resident reach two hundred dollars less than the resource limit set forth in rule 5160:1-3-05.1 of the Administrative Code or section 5163.092 of the Revised Code, as applicable, the ICFIID shall:

(a) Give written notice to the resident or the resident's representative, as applicable, that the resident may lose medicaid eligibility if the amount in the personal needs allowance account, in addition to the value of other nonexempt resources, exceeds the resource limit and retain a copy of the written notice in the resident's file; and

(b) Work with the resident or the resident's representative, as applicable, and the county department of job and family services to coordinate a spenddown plan.

(2) An ICFIID shall report to the county department of job and family services any personal needs allowance account balance in excess of the resource limit. The county department of job and family services shall apply the excess amount to the routine cost of the resident's ICFIID services.

(3) If a resident is considering using personal needs allowance funds to purchase life insurance, grave space, a burial account, or other item that may be considered a countable resource, the ICFIID shall refer the resident or the resident's representative, as applicable, to the county department of job and family services for an explanation of the effect the purchase may have on the resident's medicaid eligibility.

(F) Limitations on charges to the personal needs allowance account

(1) An ICFIID shall not charge a resident's personal needs allowance account for items and services that the ICFIID is required to furnish in order to participate in the medicaid program and that are included in medicaid payments made to the ICFIID. An ICFIID shall provide or arrange for, at no charge to a resident, any item or service that is ordered by a physician, determined medically necessary by the resident's team, and does not conflict with any state or federal regulations.

(2) Items and services that may not be purchased with personal needs allowance account funds include, but are not limited to:

(a) Nursing services;

(b) Dietary services;

(c) Activities programs;

(d) Room and board maintenance services;

(e) Routine personal hygiene items and services required to meet the needs of the resident, including but not limited to, hair hygiene supplies, comb, brush, bath soap, disinfecting soap or specialized cleansing agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, deodorant, incontinence care supplies, feminine hygiene products, towels, washcloths, hospital gowns, over-the-counter medication, hair and nail hygiene services, and basic personal laundry;

(f) Medically related social services;

(g) Medical supplies such as irrigation trays, catheters, drainage bags, syringes, and needles;

(h) Durable medical equipment;

(i) Air conditioners or charges to resident for the use of electricity;

(j) Therapy or podiatry services; and

(k) Charges for telephone consultation by physicians or other personnel.

(G) Resident requests for items and services

(1) A resident's personal needs allowance account funds may be used to purchase only those items and services requested by the resident.

(2) When a resident requests an item or service for which a charge to the resident's personal needs allowance account will be made, the ICFIID shall inform the resident that there will be a charge and the amount of the charge.

(3) An ICFIID shall not require a resident to request an item or service as a condition for admission to, or continued stay in, the ICFIID.

(H) Items and services that may be charged to the personal needs allowance account

(1) An ICFIID shall accept medicaid payment as payment in full for items and services that are covered by the medicaid program. If a resident clearly expresses a desire for a particular brand or item not available from the ICFIID, the resident's personal needs allowance funds may be used as long as a comparable item of reasonable quality is available from the ICFIID at no charge.

(2) Items and services that may be charged to a resident's personal needs allowance account include, but are not limited to:

(a) Telephone, television, or radio for the resident's exclusive use;

(b) Personal comfort items, including smoking materials, notions, novelties, and confections;

(c) Cosmetics and grooming items and services in excess of those for which payment is made under the medicaid program;

(d) Personal reading material;

(e) Stationary or stamps;

(f) Personal clothing in excess of that required by paragraph (G)(1) of rule 5123:2-3-04 of the Administrative Code;

(g) Specialty laundry services such as dry cleaning, mending, or hand-washing;

(h) Flowers or plants;

(i) Gifts purchased on behalf of a resident;

(j) Social events or entertainment offered outside the scope of the ICFIID's activities program; and

(k) Burial plots.

(I) Monitoring

The county department of job and family services shall monitor personal needs allowance accounts in accordance with section 5163.33 of the Revised Code. At least once a quarter, a designated employee of the county department of job and family services shall determine if an ICFIID is following the provisions of this rule, and shall report any questions concerning inappropriate use or inadequate record keeping of personal needs allowance funds to the department and to the Ohio department of health for further action. Inappropriate use of personal needs allowance funds by a payee or an ICFIID does not, however, reduce the scope or duration of medicaid benefits for a medicaid recipient.

Supplemental Information

Authorized By: 5123.04, 5123.28, 5124.03
Amplifies: 5123.04, 5123.28, 5124.03, 5163.33
Five Year Review Date: 12/16/2024
Rule 5123-7-12 | Intermediate care facilities for individuals with intellectual disabilities - cost report and chart of accounts.
 

(A) Purpose

This rule sets forth standards and requirements for an intermediate care facility for individuals with intellectual disabilities (ICFIID), other than a department-operated ICFIID, to submit cost reports to the department and maintain supporting documents and records.

(B) Submission of cost reports

(1) An ICFIID shall utilize the medicaid information technology system maintained by the Ohio department of medicaid to submit a cost report to the department in accordance with sections 5124.10, 5124.101, and 5124.522 of the Revised Code.

(2) For good cause, an ICFIID may request and the department may grant an extension of fourteen calendar days for submitting a cost report. An ICFIID requesting an extension shall do so in writing via email to cr-icf@dodd.ohio.gov and explain the circumstances resulting in the need for an extension. The request shall be submitted no later than ninety calendar days after the end of the reporting period.

(C) Classifying costs

(1) For purposes of the cost report, an ICFIID shall use the chart of accounts in the appendix to this rule and classify costs in accordance with applicable guidance and directives issued by the centers for medicare and medicaid services.

(a) When an account has sub-accounts, the sub-accounts shall be used to capture the information for cost reporting purposes. For example:

(i) When revenue accounts appear by payor type, charges shall be reported by payor type as applicable; and

(ii) When salary accounts differentiate between "supervisory" and "other," this level of detail shall be reported as applicable.

(b) While the chart of accounts facilitates the level of detail necessary for cost reporting purposes, an ICFIID may maintain records in a manner that allows for greater detail.

(c) The chart of accounts allows for a range of account numbers for a specified account. For example, account 1001 is for petty cash, with the next account, cash in bank, beginning at account 1010. An ICFIID may delineate sub-accounts 1010.1 to 1010.7 as separate cash accounts. An ICFIID need only use the applicable sub-accounts.

(d) Within the expense section (i.e., tables 5, 6, and 7), accounts identified as "salary" accounts are only to be used to report wages for employees of the ICFIID. Wages are to include wages for sick pay, vacation pay, and other paid time off, as well as any other compensation to be paid to an employee.

(e) Expense accounts identified as "contract" accounts are only to be used to report costs incurred for services performed by contracted personnel engaged by the ICFIID to perform a service that would otherwise be performed by personnel on the ICFIID's payroll.

(f) Expense accounts identified as "purchased nursing services" are only to be used to report costs incurred for personnel acquired through a nursing pool agency.

(g) Expense accounts designated as "other" may be used to report any appropriate non-wage expenses, including contract services and supplies.

(h) Completion of the cost report requires that the number of hours paid be reported (depending on ICFIID type of control, on an accrual or cash basis) for all salary expense accounts. An ICFIID's record keeping shall include accumulating hours paid consistent with the salary accounts included within the chart of accounts.

(2) Cost reports submitted by a county-operated ICFIID may be completed on accrual basis accounting and generally accepted accounting principles unless otherwise specified in Chapter 5123-7, 5123:2-7, or 5160-3 of the Administrative Code.

(3) All depreciable equipment valued at five hundred dollars or more per item with a useful life of at least two years, is to be reported in the capital cost component set forth in rule 5123-7-18 of the Administrative Code. The costs of equipment (including vehicles) acquired by an operating lease executed before December 1, 1992, may be reported in the indirect care cost component if the costs were reported as administrative and general costs on the ICFIID's cost report for the reporting period ending December 31, 1992, until the current lease term expires. The costs of any equipment leases executed before December 1, 1992 and reported as capital costs, shall continue to be reported under the capital cost component. The costs of any new leases for equipment executed on or after December 1, 1992, shall be reported under the capital cost component. Operating lease costs for equipment, which result from extended leases under the provision of a lease option negotiated on or after December 1, 1992, shall be reported under the capital cost component.

(4) Costs of ownership

(a) The desk-reviewed, actual, allowable, per diem costs of ownership are based upon certified beds for property costs and equipment for the calendar year preceding the fiscal year in which the rate will be paid and include:

(i) The costs of ownership directly related to purchasing or acquiring capital assets including:

(a) Except as otherwise required by paragraph (C)(4)(e) of this rule, depreciation expense for the cost of buildings equal to the actual cost depreciated in accordance with rule 5123-7-18 of the Administrative Code. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(b) Except as otherwise required by paragraph (C)(4)(e) of this rule, depreciation expense for major components of property and fixed equipment equal to the actual cost depreciated in accordance with rule 5123-7-18 of the Administrative Code. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(c) Except as otherwise required by paragraph (C)(4)(e) of this rule, depreciation expense for major movable equipment equal to the actual cost depreciated in accordance with rule 5123-7-18 of the Administrative Code. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(d) Interest expense incurred on money borrowed for construction or the purchase of real property, major components of that property, and equipment.

(e) Depreciation expense for costs paid or reimbursed by any government agency, if that part of the prospective per diem rate is used to reimburse the government agency and a loan provides for repayment over a time-limited period.

(f) Amortization expense of financing costs.

(ii) The costs of ownership directly related to renting or leasing capital assets.

(iii) The costs of ownership directly related to the amortization of leasehold improvements. These costs shall be expensed over the lesser of the remaining life of the lease, but not less than five years, or the useful life of the improvement as specified in rule 5123-7-18 of the Administrative Code. If the useful life of the improvement is less than five years, it may be amortized over its useful life. Options on leases shall not be considered. Lessees who report leasehold improvements and who leave the program before the minimum amortization period is complete shall not receive reimbursement for the balance of unamortized costs.

(b) The costs of ownership directly attributable to the purchase, rent, or lease of property and equipment costs from one related party to another through common ownership or control shall be based upon the lesser of the actual purchase, rent, or lease of property and equipment costs or the actual costs of the related party.

(i) If a provider leases or transfers an interest in an ICFIID to another provider who is a related party, the related party's allowable costs of ownership shall include the lesser of:

(a) The annual lease expense or actual costs of ownership, whichever is applicable; or

(b) The reasonable cost to the lessor or provider making the transfer.

(ii) If a provider leases or transfers an interest in an ICFIID to another provider who is a related party, regardless of the date of the lease or transfer, the related party's allowable costs of ownership shall include the annual lease expense or actual costs of ownership, whichever is applicable, if all of the following conditions are met:

(a) The related party is a relative of the owner.

(b) In the case of a lease, if the lessor retains any ownership interest, it is, except as provided in paragraph (C)(4)(b)(ii)(d)(i)(B) of this rule, in only the real property and any improvements to the real property.

(c) In the case of a transfer, the provider making the transfer retains, except as provided in paragraph (C)(4)(b)(ii)(d)(ii)(B) of this rule, no ownership interest in the ICFIID.

(d) The department determines that the lease or transfer is an arm's length transaction when:

(i) In the case of a lease:

(A) Once the lease goes into effect, the lessor has no direct or indirect interest in the lessee or, except as provided in paragraph (C)(4)(b)(ii)(b) of this rule, the ICFIID itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a lessor.

(B) The lessor does not reacquire an interest in the ICFIID except through the exercise of a lessor's rights in the event of a default. If the lessor reacquires an interest in the ICFIID in this manner, the department shall treat the ICFIID as if the lease never occurred when the department calculates its reimbursement rates for capital costs.

(ii) In the case of a transfer:

(A) Once the transfer goes into effect, the provider that made the transfer has no direct or indirect interest in the provider that acquires the ICFIID or in the ICFIID itself, including interest as an owner, officer, director, employee, independent contractor, or consultant, but excluding interest as a creditor. If the provider making the transfer maintains an interest as a creditor, the interest rate of the creditor shall not exceed the lessor of:

(1) The prime rate, as published by the "Wall Street Journal" on the first business day of the calendar year plus four per cent; or

(2) Fifteen per cent.

(B) The provider that made the transfer does not reacquire an interest in the ICFIID except through the exercise of a creditor's rights in the event of a default. If the provider reacquires an interest in the ICFIID in this manner, the department shall treat the ICFIID as if the transfer never occurred when the department calculates its reimbursement rates for capital costs.

(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 ICFIID, allowable costs of ownership was determined most recently.

(c) A provider proposing to lease or transfer an interest in an ICFIID to a related party shall provide the department with a certified appraisal for each ICFIID to be leased or transferred at least ninety calendar days prior to the actual change of the provider agreement. The certified appraisal shall be conducted no earlier than one hundred eighty calendar days prior to the actual change of the provider agreement for each ICFIID leased or transferred to a related party.

(d) A provider proposing to lease or transfer an interest in an ICFIID to a related party shall notify the department in writing and shall supply sufficient documentation demonstrating compliance with the provisions of this rule at least ninety calendar days prior to the anticipated date of completion of the transfer or lease. A provider that fails to supply the required documentation shall not qualify for a rate adjustment. The department shall issue a written decision determining whether the lease or transfer meets the requirements of this rule within sixty calendar days after receiving complete information as determined by the department.

(e) Reporting of accumulated depreciation

(i) Upon the sale of an ICFIID, the allowable capital asset cost basis, depreciation expense, and interest expense for the new provider/buyer of the ICFIID shall be the new provider's/buyer's actual depreciation and interest expense subject to the ceilings set forth in section 5124.171 of the Revised Code. If the operating rights are separately identified and valued in a sale that includes both the building and the operating rights, the operating rights shall be considered to be a part of the building for purposes of determining the allowable capital asset cost basis under this paragraph. If a new provider/buyer purchases only the operating rights to the ICFIID and uses the operating rights to create a new ICFIID or add beds to an existing ICFIID, the purchase price of the operating rights shall be added to the capital asset cost basis of the new ICFIID building or the additional beds.

(ii) Upon the sale of an ICFIID, the initial accumulated depreciation for the new provider/buyer of the ICFIID shall be recalculated starting at zero.

(5) Except for the employer's share of payroll taxes, workers' compensation, employee benefits, and home office costs, allocation of commonly shared expenses across cost centers shall not be allowed. Wages and benefits for staff, including related parties who perform duties directly related to functions performed in more than one cost center which would be expended under separate cost centers if performed by separate staff, may be expended to separate cost centers based upon documented hours worked, provided the ICFIID maintains adequate documentation of hours worked in each cost center. For example, the salary of an aide who is assigned to bathing and dressing chores in the early hours but works in the kitchen as a dietary aide for the remainder of the shift may be expended to separate cost centers provided the ICFIID maintains adequate documentation of hours worked in each cost center.

(6) The cost of purchasing resident transport vehicles is reported under the capital cost component. The cost of maintaining and repairing these vehicles is reported under the indirect care cost component.

(7) As part of its cost report, an ICFIID may complete the addendum for disputed costs to defend costs the ICFIID believes may be disputed by the department. The costs stated on the addendum are to have been applied to the other schedules and attachments for the reporting period in question (either in the reimbursable or the nonreimbursable cost centers). Any costs reported on the addendum may be considered by the department in establishing the ICFIID's prospective rate.

(8) The following costs are not reimbursable to an ICFIID through the prospective reimbursement cost reporting mechanism, except as otherwise specified in Chapter 5123-7 or 5123:2-7 of the Administrative Code:

(a) Recoupments, fines, penalties, or interest paid in accordance with sections 5124.39, 5124.41, 5124.42, 5124.523, and 5124.99 of the Revised Code.

(b) Disallowances made during an audit of the ICFIID's cost report which are sanctioned through adjudication in accordance with Chapter 119. of the Revised Code.

(c) Costs which are determined not to be reasonable and allowable costs during an audit of the ICFIID's cost report.

(d) Cost of ancillary services (e.g., physicians, legend drugs, radiology, laboratory, oxygen, or resident-specific medical equipment) rendered to residents of the ICFIID by providers who bill medicaid directly.

(e) Cost per case mix units in excess of the applicable peer group ceiling for direct care cost.

(f) Expenses in excess of the applicable peer group ceiling for indirect care cost.

(g) Expenses in excess of the capital costs limitations.

(h) Expenses associated with lawsuits filed against the department or the Ohio department of medicaid which are not upheld by the courts.

(i) Cost of meals sold to visitors or the public (e.g., meals on wheels).

(j) Cost of supplies or services sold to persons who do not reside at the ICFIID.

(k) Cost of operating a gift shop.

(D) Required disclosures

As a component of the cost report, providers shall identify:

(1) Each known related party.

(2) Each known individual, group of individuals, or organization not otherwise publicly disclosed that owns or has common ownership in whole or in part, in any mortgage, deed of trust, property, or asset of the ICFIID. When the ICFIID or the common owner is a publicly owned and traded corporation, this information beyond basic identifying criteria is not required as part of the cost report but must be available within two weeks when requested. Publicly disclosed information must be available at the time of an audit.

(3) Each corporate officer or director, if the provider is a corporation.

(4) Each partner, if the provider is a partnership.

(5) Each provider, whether participating in the medicare or medicaid program or not, which is part of an organization which is owned, or through any other device controlled, by the organization of which the provider is a part.

(6) Any director, officer, manager, employee, individual, or organization having direct or indirect ownership or control of five per cent or more, or who has been convicted of or pleaded guilty to a civil or criminal offense related to his or her involvement in programs established by Title XVIII, Title XIX, or Title XX of the Social Security Act, as in effect on the effective date of this rule. The amount of indirect ownership is determined by multiplying the percentage of ownership interest at each level (e.g., forty per cent interest in corporation "A" which owns fifty per cent of corporation "B" results in a twenty per cent indirect interest in corporation "B").

(7) Any individual currently employed by or under contract with the provider, or a related party in a managerial, accounting, auditing, legal, or similar capacity who was employed by the department, the Ohio department of medicaid, the Ohio department of health, the Ohio attorney general, the Ohio department of aging, the Ohio department of commerce, or the industrial commission of Ohio within the previous twelve months.

(E) Contracts for service

A provider shall provide upon request, each contract for service in effect during the reporting period for which the cost of the service from any subcontractor, individual, or organization is ten thousand dollars or more in a twelve-month period or for the services of a sole proprietor or partnership where there is no cost incurred and the imputed value of the service is ten thousand dollars or more in a twelve-month period. For the purposes of this paragraph:

(1) "Contract for service" is defined as the component of a contract that details services provided exclusive of supplies and equipment. It includes any contract which details services, supplies, and equipment to the extent the value of the service component is ten thousand dollars or more within a twelve-month period.

(2) "Subcontractor" is defined as any entity, including an individual or individuals, who contract with a provider to supply a service, either to the provider or directly to the beneficiary, where medicaid reimburses the provider for the cost of the service. This includes organizations related to the subcontractor that have a contract with the subcontractor for which the cost or value is ten thousand dollars or more in a twelve-month period.

(F) Preliminary determination by the department

(1) The department shall conduct a desk review of each cost report it receives. The desk review is an analysis of the cost report to determine its adequacy, completeness, and accuracy and reasonableness of the data contained therein. It is a process of reviewing information pertaining to the cost report without detailed verification and is designed to identify problems warranting additional review.

(2) Based on the desk review, the department shall make a preliminary determination of whether the reported costs are reasonable and allowable costs. "Reasonable and allowable costs" means costs established in accordance with the centers for medicare and medicaid services provider reimbursement manual (publications 15-1 and 15-2, available at https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals.html). Before issuing the preliminary determination, the department shall notify the provider of any information in the cost report that requires additional support. The provider shall provide any documentation or other information requested by the department and may submit any information that it believes supports the reported costs. The department shall notify each provider of any costs preliminarily determined not to be reasonable and allowable costs and provide the reasons for the determination.

(3) A provider may revise the cost report within sixty calendar days after the original due date without the revised information being considered an amended cost report.

(4) The cost report is considered accepted after the department has completed the desk review process.

(5) After final rates have been issued, a provider who disagrees with a preliminary determination based on the desk review may request a rate reconsideration in accordance with rule 5123-7-27 of the Administrative Code.

(G) Amending a cost report

(1) Except as provided in paragraph (G)(2) of this rule and not later than three years after a provider files a cost report with the department, 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.

(2) A provider may not amend a cost report if the Ohio department of medicaid 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 Ohio department of medicaid 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.

(3) The department shall not charge interest under division (B) of section 5124.41 of the Revised Code based on any error or additional information that is not required to be reported under this rule. The department shall review the amended cost report for accuracy and notify the provider of its determination in accordance with section 5124.107 of the Revised Code.

(H) Retention of records

(1) Financial, statistical, and medical records (which shall be available to the department, the Ohio department of medicaid, and to the United States department of health and human services and other federal agencies) supporting the cost reports or claims for services rendered to residents shall be retained for the greater of seven years after the cost report is filed if the Ohio department of medicaid issues an audit report, or six years after all appeal rights relating to the audit report are exhausted.

(2) Failure to retain the required financial, statistical, or medical records to the extent that filed cost reports are unauditable renders the provider liable for monetary damages of the greater amount:

(a) One thousand dollars per audit; or

(b) Twenty-five per cent of the amount by which the undocumented cost increased the medicaid payments to the provider during the fiscal year.

(3) Providers whose records have been found to be unauditable will be allowed sixty calendar days to provide the necessary documentation. If, at the end of the sixty calendar days, the required records have been provided and are determined auditable, the proposed penalty will be withdrawn. If the Ohio department of medicaid, after review of the documentation submitted during the sixty-day period, determines that the records are still unauditable, the department shall impose the penalty as specified in paragraph (H)(2) of this rule.

(4) Refusing access to financial, statistical, or medical records shall result in a penalty as specified in paragraph (H)(2) of this rule for outstanding medicaid services until such time as the requested information is made available to the department or the Ohio department of medicaid.

(5) All requested financial, statistical, and medical records supporting the cost reports or claims for services rendered to residents shall be available at a location in the state of Ohio for an ICFIID certified for participation in the medicaid program by this state within at least sixty calendar days after request by the state or its subcontractors. The preferred Ohio location is the ICFIID itself, but may be a corporate office, an accountant's office, or an attorney's office elsewhere in Ohio. This requirement, however, does not preclude the state or its subcontractors from the option of conducting the audit and/or a review at the site of such records if outside of Ohio.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03, 5124.10 to 5124.109, 5124.522
Five Year Review Date: 7/8/2023
Prior Effective Dates: 2/15/2018
Rule 5123-7-14 | Intermediate care facilities for individuals with intellectual disabilities - debt estimation, debt summary report, and successor liability agreements for change of operator, facility closure, involuntary termination, or voluntary termination.
 

(A) Purpose

This rule sets forth procedures for estimating the debt an exiting operator of an intermediate care facility for individuals with intellectual disabilities (ICFIID) owes the department and the federal centers for medicare and medicaid services at the time of a change of operator, facility closure, involuntary termination, or voluntary termination.

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Change of operator" has the same meaning as in section 5124.01 of the Revised Code.

(2) "Exiting operator" has the same meaning as in section 5124.01 of the Revised Code.

(3) "Facility closure" has the same meaning as in section 5124.01 of the Revised Code.

(4) "Involuntary termination" has the same meaning as in section 5124.01 of the Revised Code.

(5) "Voluntary termination" has the same meaning as in section 5124.01 of the Revised Code.

(C) Debt estimation

(1) The Ohio department of medicaid shall use the debt estimation methodology set forth in this rule to estimate an exiting operator's actual and potential debts to the department and the centers for medicare and medicaid services under the medicaid program.

(2) The Ohio department of medicaid shall total the value of all of the following that are determined applicable in calculating the debt estimate:

(a) Overpayments due to the department pursuant to section 5124.41 of the Revised Code, including:

(i) Overpayments owed for adjudicated final fiscal audit periods.

(ii) Overpayments identified in proposed adjudication orders that have been issued but not adjudicated.

(iii) Overpayment amounts for any outstanding periods where a final fiscal audit has not yet been issued. Such amounts are estimated by generating preliminary reports of amounts owed by the exiting operator for the applicable periods.

(b) Monies owed to the department and the centers for medicare and medicaid services resulting from penalties authorized by federal and state law, including but not limited to:

(i) Penalties assessed pursuant to section 5124.42 of the Revised Code for:

(a) Lack of proper notice of a change of operator, facility closure, or voluntary termination from the medicaid program; or

(b) Failure to furnish invoices or other documentation that the department requests during an audit.

(ii) Late cost report filing penalties assessed pursuant to rule 5123-7-12 of the Administrative Code.

(c) Penalties assessed pursuant to section 5124.99 of the Revised Code for violation of cost reporting provisions or provider agreement obligations.

(d) Interest monies owed to the department pursuant to section 5124.41 of the Revised Code and to the centers for medicare and medicaid services pursuant to 42 C.F.R. 488.442, as in effect on the effective date of this rule.

(e) Monies owed to the department and the centers for medicare and medicaid services pursuant to sections 5124.52 and 5124.525 of the Revised Code, including a final fiscal audit for the last fiscal year or portion thereof that the exiting operator participated in the medicaid program.

(f) Franchise permit fee owed to the department pursuant to section 5168.63 of the Revised Code which shall include unpaid franchise permit fee for:

(i) Amounts due for periods assessed or to be assessed but for which payment is not yet required pursuant to section 5168.63 of the Revised Code.

(ii) Amounts due that are certified to the Ohio attorney general's office for collection, including penalties assessed pursuant to section 5168.63 of the Revised Code for failure to pay the full amount when due.

(g) Monies owed for recapture of excess depreciation.

(h) Monies owed due to a credit balance.

(i) Monies owed pursuant to successor liability or assumption of liability agreements the exiting operator entered into.

(j) Other amounts the department determines are applicable.

(3) The sum of the amounts determined owed, or estimated to be owed, to the department and the centers for medicare and medicaid services pursuant to paragraphs (C)(2)(a) to (C)(2)(j) of this rule shall be the total estimated debt.

(4) The Ohio department of medicaid may release a portion of funds withheld pursuant to division (A) of section 5124.521 of the Revised Code if the funds withheld are materially greater than the debt calculated by the department in the initial debt summary report issued pursuant to section 5124.525 of the Revised Code.

(D) Provision of debt estimate

For the purposes of division (C) of section 5124.52 of the Revised Code, the debt estimate is considered provided by the Ohio department of medicaid on the date of mailing or date of personal service.

(E) Initial debt summary report

(1) Whenever the Ohio department of medicaid issues an initial debt summary report pursuant to section 5124.525 of the Revised Code, the Ohio department of medicaid shall give notice to the affected party informing the affected party of the affected party's right to request a review. Notice shall be given by registered mail, return receipt requested, and shall include:

(a) A statement informing the affected party that the affected party is entitled to request a review of the initial debt summary report.

(b) A statement informing the affected party that if a request for review of the initial debt summary report is not submitted on or before thirty calendar days after the mailing of the initial debt summary report, the initial debt summary report becomes the final debt summary report thirty-one calendar days after the mailing of the initial debt summary report, and that the affected party may request, in accordance with Chapter 119. of the Revised Code, an adjudication hearing regarding a finding in the 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.

(2) The Ohio department of medicaid shall also mail a copy of the notice to the affected party's attorney or other representative of record. To qualify as an attorney or representative of record, the affected party or the attorney or representative must notify the Ohio department of medicaid, in writing, that the attorney or representative is to be designated the attorney or representative of record for purposes of receiving notice of an initial debt summary report. The notification must include the address where the Ohio department of medicaid should mail the notice to the attorney or representative of record. The mailing of notice to the affected party's attorney or representative is not deemed to perfect service of the notice. Failure to mail a copy of the notice to the attorney or representative of record will not result in failure of otherwise perfected service upon the affected party. In those instances where an affected party is a corporation doing business in Ohio or is incorporated in Ohio, the mailing of notice to the corporation's statutory agent pursuant to sections 1701.07 and 1703.19 of the Revised Code will perfect service.

(3) When any notice of an initial debt summary report sent by registered mail pursuant to this rule is returned because the affected party fails to claim the notice, the Ohio department of medicaid shall send the notice by ordinary mail to the affected party at the affected party's last known address and shall obtain a certificate of mailing. Service by ordinary mail is complete when the certificate of mailing is obtained unless the notice is returned showing failure of delivery.

(4) When any notice of an initial debt summary report sent by registered mail or ordinary mail is returned for failure of delivery, the Ohio department of medicaid shall make personal delivery of the notice by an employee or agent of the Ohio department of medicaid. An employee or agent of the Ohio department of medicaid may make personal delivery of the notice upon a party at any time.

(5) Refusal of delivery of an initial debt summary report by personal service or by mail is not failure of delivery and service is deemed to be complete at the time of personal refusal or at the time of receipt by the Ohio department of medicaid of the refused mail as evidenced by the Ohio department of medicaid date and time stamp. Failure of delivery occurs only when a mailed notice is returned by the postal authorities marked undeliverable, address or addressee unknown, or forwarding address unknown or expired.

(6) Any request for a review made as the result of notice of an initial debt summary report issued pursuant to this rule must be made in writing and mailed or delivered to the Ohio department of medicaid office and address identified in the initial debt summary report within thirty calendar days of the following, as applicable:

(a) The time of mailing the notice if notice is given pursuant to paragraph (E)(1) of this rule.

(b) The date that service is complete if notice is given pursuant to paragraph (E)(3) or (E)(5) of this rule.

(c) The date of personal service.

(7) If a request for review is mailed to the Ohio department of medicaid office and address identified in the initial debt summary report, the request is deemed to have been made:

(a) If the request for review is mailed by certified mail, as of the date stamped by the United States postal service on its receipt form.

(b) If the request for review is mailed by regular United States mail, as of the date of the postmark appearing upon the envelope containing the request.

(c) If the request for review is mailed by regular United States mail and the postmark is illegible or fails to appear on the envelope, as of the date of its receipt by the Ohio department of medicaid office identified in the initial debt summary report as evidenced by that office's date and time stamp.

(8) If a request for review is made by electronic mail to the office identified in the initial debt summary report, the request is deemed to have been made as of the date of its receipt as evidenced by the date of receipt shown in the source code of the electronic mail received by the office identified in the initial debt summary report.

(9) If a request for review is mailed, personally delivered, or made by electronic mail to a party or address other than the proper office identified in the initial debt summary report, the request is deemed to have been made as of the date of its receipt by the office identified in the initial debt summary report as evidenced by that office's date and time stamp.

(10) If a request for review is personally delivered to the office identified in the initial debt summary report, the request is deemed to have been made as of the date of its receipt as evidenced by that office's date and time stamp.

(11) All requests for review must clearly identify both the affected party involved and the initial debt summary report that is being contested.

(F) Revised debt summary report

(1) Whenever the Ohio department of medicaid issues a revised debt summary report pursuant to section 5124.525 of the Revised Code, the Ohio department of medicaid shall give notice to the affected party informing the affected party of the affected party's right to submit additional information. Notice shall be given by registered mail, return receipt requested, and shall include:

(a) A statement informing the affected party that the affected party is entitled to submit additional information.

(b) A statement informing the affected party that if additional information is not submitted on or before thirty calendar days after the mailing of the revised debt summary report, the revised debt summary report becomes the final debt summary report thirty-one calendar days after the mailing of the revised debt summary report, and that the affected party may request, in accordance with Chapter 119. of the Revised Code, an adjudication hearing regarding a finding in the 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.

(2) The Ohio department of medicaid shall also mail a copy of the notice to the affected party's attorney or other representative of record. To qualify as an attorney or representative of record, the affected party or the attorney or representative must notify the Ohio department of medicaid, in writing, that the attorney or representative is to be designated the attorney or representative of record for purposes of receiving notice of a revised debt summary report. The notification must include the address where the Ohio department of medicaid should mail the notice to the attorney or representative of record. The mailing of notice to the affected party's attorney or representative is not deemed to perfect service of the notice. Failure to mail a copy of the notice to the attorney or representative of record will not result in failure of otherwise perfected service upon the affected party. In those instances where an affected party is a corporation doing business in Ohio or is incorporated in Ohio, the mailing of notice to the corporation's statutory agent pursuant to sections 1701.07 and 1703.19 of the Revised Code will perfect service.

(3) When any notice of a revised debt summary report sent by registered mail pursuant to this rule is returned because the affected party fails to claim the notice, the Ohio department of medicaid shall send the notice by ordinary mail to the affected party at the affected party's last known address and shall obtain a certificate of mailing. Service by ordinary mail is complete when the certificate of mailing is obtained unless the notice is returned showing failure of delivery.

(4) When any notice of a revised debt summary report sent by registered mail or ordinary mail is returned for failure of delivery, the Ohio department of medicaid shall make personal delivery of the notice by an employee or agent of the Ohio department of medicaid. An employee or agent of the Ohio department of medicaid may make personal delivery of the notice upon a party at any time.

(5) Refusal of delivery of a revised debt summary report by personal service or by mail is not failure of delivery and service is deemed to be complete at the time of personal refusal or at the time of receipt by the Ohio department of medicaid of the refused mail as evidenced by the Ohio department of medicaid date and time stamp. Failure of delivery occurs only when a mailed notice is returned by the postal authorities marked undeliverable, address or addressee unknown, or forwarding address unknown or expired.

(6) Any submission of additional information made as the result of notice of a revised debt summary report issued pursuant to this rule must be made in writing and mailed or delivered to the Ohio department of medicaid office and address identified in the revised debt summary report within thirty calendar days of the following, as applicable:

(a) The time of mailing the notice if notice is given pursuant to paragraph (F)(1) of this rule.

(b) The date that service is complete if notice is given pursuant to paragraph (F)(3) or (F)(5) of this rule.

(c) The date of personal service.

(7) If a submission of additional information is mailed to the Ohio department of medicaid office and address identified in the revised debt summary report, the request is deemed to have been made:

(a) If the submission of additional information is mailed by certified mail, as of the date stamped by the United States postal service on its receipt form.

(b) If the submission of additional information is mailed by regular United States mail, as of the date of the postmark appearing upon the envelope containing the request.

(c) If the submission of additional information is mailed by regular United States mail and the postmark is illegible or fails to appear on the envelope, as of the date of its receipt by the Ohio department of medicaid office identified in the revised debt summary report as evidenced by that office's date and time stamp.

(8) If a submission of additional information is made by electronic mail to the office identified in the revised debt summary report, the submission is deemed to have been made as of the date of its receipt as evidenced by the date of receipt shown in the source code of the electronic mail received by the office identified in the revised debt summary report.

(9) If a submission of additional information is mailed, personally delivered, or made by electronic mail to a party or address other than the proper office identified in the revised debt summary report, the submission is deemed to have been made as of the date of its receipt by the office identified in the revised debt summary report as evidenced by that office's date and time stamp.

(10) If a submission of additional information is personally delivered to the office identified in the revised debt summary report, the submission is deemed to have been made as of the date of its receipt as evidenced by that office's date and time stamp.

(11) All submissions of additional information must clearly identify both the affected party involved and the revised debt summary report that is being contested.

(G) Final debt summary report

Rule 5101:6-50-03 of the Administrative Code shall apply if an affected party timely submits a request for review and additional information in response to a revised debt summary report, and the Ohio department of medicaid issues a final debt summary report pursuant to section 5124.525 of the Revised Code. An adjudication on a final debt summary report shall be conducted only with respect to findings in the final debt summary report that pertain 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.

(H) Computation of time deadlines

Section 1.14 of the Revised Code controls the computing of time deadlines imposed by this rule. The time within which an act is required by law to be completed is computed by excluding the first day and including the last day. When the last day falls on a Saturday, Sunday, or legal holiday, the act may be completed on the next succeeding day that is not a Saturday, Sunday, or legal holiday. When the last day to perform an act that is required by law is to be performed in a public office and that public office is closed to the public for the entire day, the act may be performed on the next succeeding day that is not a Saturday, Sunday, or legal holiday.

(I) Successor liability agreements

(1) Successor liability agreements entered into pursuant to section 5124.521 of the Revised Code are subject to approval by the Ohio department of medicaid.

(2) Successor liability agreements must be signed by the exiting operator, the Ohio department of medicaid, and the entity assuming liability pursuant to section 5124.521 of the Revised Code.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03, 5124.41, 5124.42, 5124.52, 5124.521, 5124.525, 5124.99, 5168.63
Five Year Review Date: 12/16/2024
Prior Effective Dates: 1/10/2013
Rule 5123-7-18 | Intermediate care facilities for individuals with intellectual disabilities - capital assets and depreciation.
 

(A) Purpose

This rule establishes requirements for determining when an asset of an intermediate care facility for individuals with intellectual disabilities (ICFIID) is capitalized and depreciated.

(B) Capitalization of assets

For purposes of determining when an asset is capitalized, an ICFIID shall use the following guidelines:

(1) Any item that costs five hundred or more dollars and has a useful life of two or more years shall be capitalized and depreciated over the asset's useful life.

(2) An ICFIID that has a capitalization policy in effect on the effective date of this rule to capitalize items that cost less than five hundred dollars shall continue to follow its policy and shall obtain prior approval from the department to change its policy.

(C) Determining useful life

For purposes of determining the useful life of a capital asset, an ICFIID shall use:

(1) The internal revenue service publication 946, "How to Depreciate Property" (2017), available at http://www.irs.gov/publications/p946/index.html;

(2) The American hospital association's "Estimated Useful Lives of Depreciable Hospital Assets" (2018);

(3) The appendix to rule 5123:2-7-18 of the Administrative Code as it existed on the day immediately prior to the effective date of this rule; or

(4) Another method approved by the department.

(D) Depreciation

(1) Depreciation on buildings, components of a building, and medical equipment used in the provision of resident care that is not reimbursable directly to the medical equipment supplier in accordance with rule 5123:2-7-11 of the Administrative Code is an allowable cost.

(2) For purposes of calculating depreciation expense, an ICFIID shall use the following guidelines:

(a) All capital assets shall be depreciated using the straight-line method of depreciation.

(b) In the month that a capital asset is placed into service, no depreciation expense is recognized as an allowable expense. A full month's depreciation expense is recognized in the month following the month the asset is placed into service.

(c) In the month that a capital asset is disposed, if the capital asset is not fully depreciated, the allowable depreciation expense is recognized as it is defined in section 132 of the centers for medicare and medicaid services publication 15-1, "Provider Reimbursement Manual" (revised January 2005), available at http://www.cms.hhs.gov/manuals. At no time shall a capital asset be depreciated more than its adjusted basis.

(d) An ICFIID shall maintain, and provide to the department upon request, detailed depreciation schedules to verify each individual capital asset placed in service.

(E) Salvage value

For purposes of determining the salvage value of a capital asset, an ICFIID shall use the following guidelines:

(1) An ICFIID shall maintain, and provide to the department upon request, documentation demonstrating the salvage value for any capital asset determined to have a salvage value of less than ten per cent.

(2) When an ICFIID determines that a capital asset does not have a salvage value, the ICFIID shall record a salvage value of zero dollars in its asset ledger.

(3) If an ICFIID previously recorded a ten per cent salvage value for a capital asset that is still in use and that has a salvage value of less than ten per cent, the salvage value may be added to the capital asset and expensed over the remaining useful life of the capital asset. The ICFIID may revise unaudited cost reports accordingly for years where final cost settlement has not occurred.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03
Five Year Review Date: 12/16/2024
Prior Effective Dates: 1/10/2013
Rule 5123-7-20 | Intermediate care facilities for individuals with intellectual disabilities - resident assessment classification system based on administration of the individual assessment form.
 

(A) Purpose

This rule sets forth a method and process for determining the per resident/per day rate paid to an intermediate care facility for individuals with intellectual disabilities (ICFIID) for direct care costs using the individual assessment form pursuant to sections 5124.195 to 5124.198 of the Revised Code.

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Annual facility average case mix score" means the ICFIID's average case mix score of all qualifying quarters in a calendar year.

(2) "Case mix score" means the measure of the relative direct care resources needed to provide care and rehabilitation to a resident of an ICFIID using the individual assessment form.

(3) "Correction submission due date" means the deadline for an ICFIID to submit corrected individual assessment form data to the department. The correction submission due date applies to corrections submitted in electronic format for facility level errors and resident record changes.

(4) "Cost per case mix unit" is calculated by dividing an ICFIID's desk-reviewed, actual, allowable, per diem direct care costs for the calendar year preceding the fiscal year in which the rate will be paid by the annual facility average case mix score for the calendar year preceding the fiscal year in which the rate will be paid.

(5) "Facility level errors" means errors which must be corrected before a facility average case mix score can be calculated and include:

(a) Failure to electronically submit the certification of individual assessment form data by the correction submission due date.

(b) Incomplete or inaccurate data are submitted to the department.

(c) The number of individual assessment form records processed is more than the reported number of residents in medicaid-certified beds on the reporting period end date.

(6) "Filing date" means the deadline for initial quarterly electronic submission and certification of an ICFIID's individual assessment form data, which is the fifteenth calendar day following the reporting period end date.

(7) "Individual assessment form" means the instrument used to assess the needs and circumstances of an individual with developmental disabilities for the purpose of calculating an ICFIID's direct care costs pursuant to sections 5124.195 to 5124.198 of the Revised Code.

(8) "Ohio developmental disabilities profile" means the instrument used to assess the needs and circumstances of an individual with developmental disabilities for the purpose of calculating an ICFIID's direct care component rate pursuant to sections 5124.19 to 5124.193 of the Revised Code.

(9) "Peer group" means one of the following groups of ICFIID:

(a) "Peer group 1-B" includes each ICFIID with a medicaid-certified capacity exceeding eight.

(b) "Peer group 2-B" includes each ICFIID with a medicaid-certified capacity not exceeding eight, other than an ICFIID that is in peer group 3-B.

(c) "Peer group 3-B" includes each ICFIID to which all of the following apply:

(i) The ICFIID is first certified as an ICFIID after July 1, 2014;

(ii) The ICFIID has a medicaid-certified capacity not exceeding six;

(iii) The ICFIID has a contract with the department that is for fifteen years and includes a provision for the department to approve all admissions to, and discharges from, the ICFIID; and

(iv) The ICFIID's residents are admitted to the ICFIID directly from a department-operated ICFIID or have been determined by the department to be at risk of admission to a department-operated ICFIID.

(10) "Processing quarter" means the quarter that follows the reporting quarter and is the quarter in which the department receives the individual assessment form data for the reporting quarter.

(11) "Quarterly facility average case mix score" means the facility average case mix score based on individual assessment form data submitted for one reporting quarter.

(12) "Record" means a resident's individual assessment form data processed by the department.

(13) "Relative resource weight" means the measure of the relative costliness of caring for residents in one case mix classification versus another, indicating the relative amount and cost of staff time required on average for defined job types to care for residents in a single case mix classification.

(14) "Reporting period end date" means the last day of each calendar quarter.

(15) "Reporting quarter" means the quarter which precedes the processing quarter.

(16) "Resident assessment classification system" means the system for classifying residents of an ICFIID into case mix classifications that reflect clusters of residents, defined by resident characteristics determined using data from the individual assessment form, that explain resource use.

(17) "Resident case mix score" means the relative resource weight for the classification to which a resident is assigned based on data elements from the resident's individual assessment form.

(C) Calculating direct care costs

For a period of three years commencing on the effective date of this rule, the department shall calculate for each eligible ICFIID, two separate per resident/per day rates for direct care costs using data from:

(1) Administration of the individual assessment form to residents of the ICFIID in accordance with this rule; and

(2) Administration of the Ohio developmental disabilities profile to residents of the ICFIID in accordance with rules 5123-7-33 and 5123:2-7-32 of the Administrative Code.

(D) Resident assessment classification system

(1) The department shall use the resident assessment classification system to classify residents of an ICFIID based on data from the individual assessment form. Residents in each classification utilize similar quantities and patterns of resources. Based upon the data collected in the individual assessment form, a resident that meets the criteria for placement in more than one classification shall be placed in the highest classification according to the hierarchy. Residents without characteristics resulting in assignment to the higher classifications shall be placed in the sixth classification.

(2) The resident assessment classification system defines criteria used to assign residents to one of six mutually exclusive classifications listed in descending order of the hierarchy:

(a) The chronic medical classification includes residents receiving one or more of the following types of special care:

(i) Parenteral therapy on all shifts (on the individual assessment form at the medical domain section, item 24 is scored "4"),

(ii) Tracheostomy care/suctioning on all shifts (on the individual assessment form at the medical domain section, item 25 is scored "4"),

(iii) Oxygen and respiratory therapy on all shifts (on the individual assessment form at the medical domain section, item 27 is scored "4"),

(iv) Oral medication administered more than eight times in a twenty-four-hour day (on the individual assessment form at the medical domain section, item 29a is scored "3"),

(v) Topical medication administered more than eight times in a twenty-four-hour day (on the individual assessment form at the medical domain section, item 29b is scored "3"),

(vi) Injections of medication administered more than eight times in a twenty-four-hour day (on the individual assessment form at the medical domain section, item 29c is scored "3"),

(vii) Medication administered more than eight times in a twenty-four-hour day using a method other than oral, topical, or injection (on the individual assessment form at the medical domain section, item 29d is scored "3"), and/or

(viii) Utilization of out-of-home health care requiring over thirty days of staff time on average per year (on the individual assessment form at the medical domain section, item 31 is scored "3").

(b) The overriding behaviors classification includes residents exhibiting one or more of the following specific behaviors that require continual staff intervention as defined in the individual assessment form instructions:

(i) Aggressive behavior (on the individual assessment form at the behavior domain section, item 14 is scored "3"),

(ii) Self-injurious behavior (on the individual assessment form at the behavior domain section, item 17 is scored "3"), and/or

(iii) Acute suicidal behavior (on the individual assessment form at the behavior domain section, item 21 is scored "3").

(c) The high adaptive needs and chronic behaviors classification includes residents requiring a specific level of staff assistance/supervision for one or more personal care and safety needs described in paragraphs (D)(2)(c)(i) to (D)(2)(c)(vi) of this rule and exhibiting one or more of the behaviors described in paragraphs (D)(2)(c)(vii) to (D)(2)(c)(x) of this rule that require frequent or continual staff intervention as defined in the individual assessment form instructions:

(i) Eating (on the individual assessment form at the adaptive skills domain section, item 1 is scored "2" for needing hands-on assistance),

(ii) Toileting (on the individual assessment form at the adaptive skills domain section, item 2 is scored either "3" for as a rule does not indicate the need to toilet and requires assistance with wiping, or "4" for requires colostomy, ileostomy, or urinary catheter),

(iii) Dressing (on the individual assessment form at the adaptive skills domain section, item 5 is scored "3" for requiring hands-on assistance and/or constant supervision to complete the tasks, or tasks must be done completely by staff for the resident),

(iv) Turning and positioning more than twelve times in a twenty-four-hour period (on the individual assessment form at the adaptive skills domain section, item 6 is scored "4"),

(v) Mobility requiring the help of one or more persons (on the individual assessment form at the adaptive skills domain section, item 7 is scored "3"),

(vi) Transfer requiring direction and/or physical help from one or more persons (on the individual assessment form at the adaptive skills domain section, item 8 is scored "2"),

(vii) Aggressive behavior requiring frequent staff intervention as defined in the instructions for completing the individual assessment form (on the individual assessment form at the behavior domain section, item 14 is scored "2"),

(viii) Self-injurious behavior requiring frequent staff intervention as defined in the instructions for completing the individual assessment form (on the individual assessment form at the behavior domain section, item 17 is scored "2"),

(ix) Disruptive behavior requiring continual staff intervention as defined in the individual assessment form (on the individual assessment form at the behavior domain section, item 19 is scored "4"), and/or

(x) Withdrawn behavior requiring continual staff intervention as defined in the instructions for completing the individual assessment form (on the individual assessment form at the behavior domain section, item 20 is scored "3").

(d) The high adaptive needs and non-significant behaviors classification includes residents requiring a specific level of staff assistance/supervision for one or more personal care and safety needs described in paragraphs (D)(2)(c)(i) to (D)(2)(c)(vi) of this rule.

(e) The chronic behaviors and typical adaptive needs classification includes residents exhibiting one or more of the behaviors described in paragraphs (D)(2)(c)(vii) to (D)(2)(c)(x) of this rule that require frequent or continual staff intervention as defined in the individual assessment form instructions.

(f) The typical adaptive needs and non-significant behaviors classification includes residents not meeting the criteria of the other five classifications.

(E) Relative resource weights

(1) Analysis of staff time and resident assessment data, collected in a work measurement study of Ohio medicaid-certified ICFIID for the purpose of establishing common staff times associated with all resident classifications that are standard across residents, staff, facilities, and units, determined that the job classifications listed in paragraphs (E)(1)(a) to (E)(1)(h) of this rule are job types that perform activities that vary by case mix classification established using the individual assessment form. Job types determined not to be positions participating in activities that vary by case mix classification are not used to calculate the relative resource weights as described in paragraph (E)(2) of this rule.

(a) Habilitation specialists consisting of nurse aides and habilitation staff;

(b) Licensed practical nurses;

(c) Occupational therapists;

(d) Program specialists;

(e) Qualified intellectual disability professionals;

(f) Registered nurses;

(g) Social workers/counselors; and

(h) Speech therapists.

(2) Each of the six resident classifications is assigned a relative resource weight. The relative resource weight indicates the relative amount and cost of staff time required on average for the job types listed in paragraphs (E)(1)(a) to (E)(1)(h) of this rule to deliver care to residents in that classification. The relative resource weight was calculated using the average minutes of care per job type per classification as determined during the work measurement study, and the averages of the wages by job type as reported on the cost report. By setting the wage weight at one for the job type receiving the lowest hourly wage, wage weights for the other job types are calculated by dividing the lowest wage into the wage of each of the other job types. To calculate the total weighted minutes for each classification, the wage weight for each job type is multiplied by the average number of minutes staff of that job type spend caring for a resident in that classification, and the products are summed. The classification with the lowest total weighted minutes receives a relative resource weight of one. Relative resource weights are calculated by dividing the total weighted minutes of the lowest classification into the total weighted minutes of each classification. Weight calculations are rounded to the fourth decimal place. Relative resource weights for the resident classifications are:

(a) Chronic medical = 2.0888.

(b) Overriding behaviors = 1.9206.

(c) High adaptive needs and chronic behaviors = 1.8935.

(d) High adaptive needs and non-significant behaviors = 1.7434.

(e) Chronic behaviors and typical adaptive needs = 1.3593.

(f) Typical adaptive needs and non-significant behaviors = 1.000.

(3) Except as provided in paragraph (E)(3)(a) of this rule, relative resource weights may be recalibrated using wage weights based on three-year statewide averages of wages of the job types listed in this rule as reported on the cost report, and minutes of care per job type per resident assessment classification.

(a) The department may recalibrate the relative resource weights no more often than every three years, using the minutes of care per job type per classification from the most current work measurement study and the wages per job type per hour, to be effective at the beginning of the next state fiscal year. When recalibrating the relative resource weights, the department shall use cost report wage data from the most recent three calendar years available ninety calendar days prior to the start of the fiscal year.

(b) The department may recalibrate relative resource weights more frequently if significant variances in wage ratios between job types occur.

(c) The department may rebase the relative resource weights through the deletion or addition of job types or with revised minutes of care per job type by conducting a new work measurement study, if significant changes in the job types or work roles of the job types occur, or following a change in state policy which would significantly affect statewide case mix of the ICFIID population.

(d) After recalibrating or rebasing relative resource weights in accordance with paragraph (E)(3)(a), (E)(3)(b), or (E)(3)(c) of this rule, the department shall use the recalibrated or rebased relative resource weights to recalculate the annual facility average case mix score for the calendar year preceding the fiscal year.

(F) Collection and submission of individual assessment form data

(1) The department shall process individual assessment form data submitted by an ICFIID and classify residents using the resident assessment classification system to determine resident case mix scores. These resident case mix scores, based on relative resource weights as set forth in paragraph (E) of this rule, are used to establish the quarterly facility average case mix score. The method for determining the quarterly facility average case mix score is described in paragraph (G)(4) of this rule.

(2) The individual assessment form shall be administered by ICFIID staff authorized by the department. In order to become authorized, ICFIID staff shall attend and successfully complete a training session conducted or approved by the department that includes a demonstration.

(3) Each ICFIID shall use the individual assessment form software provided by the department at no cost to complete and electronically submit to the department through the department's website (http://dodd.ohio.gov) a quarterly case mix assessment for each resident of the ICFIID, regardless of payment source or anticipated length of stay, to reflect the resident's condition on the reporting period end date, which is the last day of the calendar quarter. The electronic data shall be submitted in the exact layout provided in the individual assessment form software.

(4) The following shall be considered residents of the ICFIID on the reporting period end date:

(a) Residents admitted or transferred to the ICFIID prior to or on the reporting period end date and physically residing in the ICFIID on the reporting period end date; and

(b) Residents temporarily absent on the reporting period end date but for whom the ICFIID is receiving payment from any source to hold a bed for the resident during a hospital stay, visit with friends or relatives, or participation in therapeutic programs outside the facility in accordance with rule 5123:2-7-08 of the Administrative Code.

(5) The following shall not be considered residents of the ICFIID on the reporting period end date:

(a) Residents discharged from the ICFIID prior to or on the reporting period end date; and

(b) Residents transferred to another ICFIID prior to or on the reporting period end date; and

(c) Residents who die prior to or on the reporting period end date.

(6) An ICFIID shall complete and electronically submit a certification of individual assessment form data with the quarterly submission of individual assessment form data identifying the name of the ICFIID, its provider number, the total number of beds the ICFIID has certified by the Ohio department of health for medicaid, total number of residents in the ICFIID as of the reporting period end date for whom the ICFIID must submit an individual assessment form, and the name of the authorized staff member who administered the individual assessment form for each resident. The certification of individual assessment form data shall be electronically submitted to the department no later than the fifteenth day of the month following the reporting period end date.

(7) The annual facility average case mix score calculated in accordance with this rule is used in conjunction with the lesser of the ICFIID's cost per case mix unit or the maximum allowable cost per case mix unit, adjusted by the inflation rate, to establish the direct care rate, as outlined in sections 5124.195 to 5124.198 of the Revised Code. The ICFIID's cost per case mix unit is calculated using the annual facility average case mix score. The method for determining the annual facility average case mix score is described in paragraph (H) of this rule.

(G) Quarterly facility average case mix score

(1) The department shall establish each ICFIID's rate for direct care costs using data from the individual assessment form, annually pursuant to sections 5124.195 to 5124.198 of the Revised Code. The department shall assign a quarterly facility average case mix score or cost per case mix unit used to establish an ICFIID's rate for direct care costs if the ICFIID fails to certify individual assessment form data in accordance with this rule or fails to correct facility level errors. Before taking such action, the department shall permit the ICFIID a reasonable period of time to correct the information, as described in paragraph (G)(3)(c) of this rule. To set the rate, the department shall:

(a) Calculate the ICFIID's cost per case mix unit;

(b) Multiply the lesser of the ICFIID's cost per case mix unit or the maximum cost per case mix unit for the ICFIID's peer group determined pursuant to division (C) of section 5124.195 of the Revised Code by the ICFIID's annual average case mix score for the calendar year preceding the fiscal year for which the rate is set begins; and

(c) Multiply the amount determined in accordance with paragraph (G)(1)(b) of this rule by the inflation factor specified in division (D) of section 5124.195 of the Revised Code.

(2) The department shall calculate and use the actual quarterly facility average case mix score described in paragraph (G)(4) of this rule for determining the direct care rate if:

(a) The ICFIID submits individual assessment form data by the filing date and includes assessments for all residents of the ICFIID as of the reporting period end date;

(b) In accordance with the procedures outlined in paragraph (G)(3) of this rule for correcting inaccurate information, the ICFIID timely submits and timely corrects individual assessment form data for that reporting quarter; and

(c) The ICFIID's submission and certification of individual assessment form data does not contain facility level errors or such errors have been timely corrected.

(3) After the department has processed the ICFIID's individual assessment form data for a reporting quarter, the department shall make available the "Case Mix Provider Summary Report" to the ICFIID. The ICFIID may correct errors or omissions identified by either the department or the ICFIID by sending in a modification submission and submitting corrections to the department along with an amended certification of individual assessment form data.

(a) The department shall notify an ICFIID of a missing or incomplete certification of individual assessment form data.

(b) The department may notify an ICFIID of its initial quarterly submission through two documents:

(i) The "Submission Tracking Summary" report which shows the status of the individual assessment form data after initial processing by the department.

(ii) The "Detailed Listing of Successfully Grouped Assessments" report which is a list of individual assessment form records that were grouped into resident assessment classification system groups one through six.

(c) The department shall allow forty-five calendar days after the reporting period end date for an ICFIID to make corrections and return them to the department. Timeliness of the submission to the department shall be determined by the electronic submission date.

(d) Corrections received by the department shall be used in computing the quarterly facility average case mix score, in accordance with the conditions outlined in paragraph (G)(2) of this rule.

(e) The department shall process corrections submitted in electronic format if the file format is the same as used by the department.

(f) Changes made on the individual assessment form modification submission data element entries must be consistent with changes made to the original individual assessment form maintained at the ICFIID.

(4) The quarterly facility average case mix score for an ICFIID that submitted individual assessment form data and modifications timely, and has no facility level errors is calculated by:

(a) Adding together all residents' relative resource weights for the quarter; and

(b) Dividing the sum of relative resource weights by the total number of residents.

(5) The department may assign a quarterly facility average case mix score that is five per cent less than the ICFIID's quarterly facility average case mix score for the preceding calendar quarter instead of using the quarterly facility average case mix score calculated based on the ICFIID's submitted information as described in paragraph (G)(4) of this rule.

(a) If the ICFIID was subject to an exception review conducted pursuant to rule 5123-7-30 of the Administrative Code for the preceding calendar quarter, the assigned quarterly facility average case mix score shall be the score that is five per cent less than the score determined by the exception review.

(b) If the ICFIID was assigned a quarterly facility average case mix score for the preceding calendar quarter, the assigned quarterly facility average case mix score shall be the score that is five per cent less than that score assigned for the preceding quarter.

(6) The department may assign a cost per case mix unit that is five per cent less than the ICFIID's calculated or assigned cost per case mix unit for the preceding calendar year if the ICFIID has fewer than two acceptable quarterly facility average case mix scores.

(H) Annual facility average case mix score

(1) The annual facility average case mix score is used to compute the cost per case mix unit for the ICFIID and the peer group maximum cost per case mix unit for the purpose of calculating direct care rates pursuant to sections 5124.195 to 5124.198 of the Revised Code. Individual assessment form data for all four quarters of the calendar year shall be used to calculate the annual facility average case mix score.

(a) The department-assigned facility average case mix scores shall be omitted from the ICFIID's annual average case mix score calculation.

(b) The annual facility average case mix score shall be calculated from no fewer than two acceptable quarterly facility average case mix scores. Acceptable quarterly facility average case mix scores shall be summed and divided by the total number of quarters of acceptable scores. Acceptable quarterly facility average case mix scores for the purposes of calculating the annual facility average case mix score include, in order of hierarchy:

(i) Adjusted quarterly facility average case mix scores as a result of exception review findings, or

(ii) Quarterly facility average case mix scores calculated based on the ICFIID's submitted information as described in paragraph (G)(4) of this rule.

(2) If at least two acceptable quarterly facility average case mix scores are not available, the department shall assign the cost per case mix unit in accordance with paragraph (G)(6) of this rule.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03, 5124.195 to 5124.198
Five Year Review Date: 7/8/2023
Prior Effective Dates: 1/10/2013, 10/1/2013, 10/1/2014
Rule 5123-7-21 | Intermediate care facilities for individuals with intellectual disabilities - compensation cost limits for owners and relatives of owners.
 

(A) Purpose

This rule establishes limits, applicable to the cost report of an intermediate care facility for individuals with intellectual disabilities (ICFIID), for the amount of compensation that may be claimed for owners or relatives of owners of the ICFIID.

(B) Calculating compensation cost limits for owners and relatives of owners serving in positions for which comparable positions exist

Compensation cost limits for owners and relatives of owners shall be based upon compensation costs for persons who hold comparable positions but who are not owners or relatives of owners, as reported on the ICFIID's cost report from the calendar year preceding the fiscal year in which the rate is paid. As used in this rule, "comparable position" means the position that is held by the owner or relative of an owner, if that position is listed separately on the ICFIID's cost report, or if the position is not listed separately, the group of positions that is listed on the ICFIID's cost report and that includes the position held by the owner or relative of an owner. The compensation cost limits for owners and relatives of owners who function in positions listed on attachment 6 of the cost report shall be based upon the wage and hour equivalents which are calculated as follows:

(1) The compensation cost limits for owners and relatives of owners are calculated from:

(a) Cost reports with a December thirty-first end date; and

(b) Desk-reviewed and preliminarily determined to be allowable costs.

(2) For each wage and hour chart of account number from attachment 6 of the cost report, calculate the compensation cost limits as follows:

(a) Calculate the total non-owner wages paid by summing the total non-owner wages paid (column E) for all providers that have amounts reported in columns (E) and (H) of attachment 6.

(b) Calculate the total non-owner hours paid by summing the total non-owner hours paid (column H) for all providers that have amounts reported in columns (E) and (H) of attachment 6.

(c) Calculate the average hourly rate by dividing the total non-owner wages paid as calculated in accordance with paragraph (B)(2)(a) of this rule by the total non-owner hours paid as calculated in accordance with paragraph (B)(2)(b) of this rule.

(d) Calculate the compensation cost limit by multiplying the average hourly rate as calculated in accordance with paragraph (B)(2)(c) of this rule by two thousand eighty hours.

(C) Calculating compensation cost limits for owners and relatives of owners serving in positions for which comparable positions do not exist

Compensation cost limits for owners and relatives of owners who serve the ICFIID in a capacity such as corporate officer, for which no comparable position or group of positions is listed on attachment 6 of the cost report shall be based upon the civil service equivalents set forth in rule 123:1-7-15 of the Administrative Code. Compensation for owners and relatives of owners that are corporate officers is allowable for managerial, administrative, professional, and other services related to the operation of the ICFIID and rendered in connection with resident care. The compensation cost limit for an owner or relative of an owner who functions in a corporate position shall be based upon the civil service equivalents as listed below. In the case of an owner or relative of an owner who functions as proprietor or partner, one of the below-listed civil service equivalents shall be applied based upon the duties performed:

(1) Corporate president

(a) Business administrator 3, classification 63317, for facilities with a combined bed total of one to ninety-nine;

(b) Business administrator 4, classification 63318, for facilities with a combined bed total of one hundred to one hundred ninety-nine;

(c) Fiscal officer 4, classification 66538, for facilities with a combined bed total of two hundred to two hundred ninety-nine;

(d) Director 1, classification 61111, for facilities with a combined bed total of three hundred to five hundred ninety-nine;

(e) Director 2, classification 61112, for facilities with a combined bed total of six hundred to one thousand one hundred ninety-nine; or

(f) Director 3, classification 61113, for facilities with a combined bed total of one thousand two hundred or more.

(2) Corporate vice-president

(a) Program administrator 2, classification 63123, for facilities with a combined bed total of one to ninety-nine;

(b) Program administrator 3, classification 63124, for facilities with a combined bed total of one hundred to one hundred ninety-nine;

(c) Assistant director 1, classification 61211, for facilities with a combined bed total of two hundred to two hundred ninety-nine;

(d) Assistant director 2, classification 61212, for facilities with a combined bed total of three hundred to five hundred ninety-nine;

(e) Assistant director 3, classification 61213, for facilities with a combined bed total of six hundred to one thousand one hundred ninety-nine; or

(f) Assistant director 4, classification 61214, for facilities with a combined bed total of one thousand two hundred or more.

(3) Corporate treasurer

(a) Fiscal specialist 1, classification 66531, for facilities with a combined bed total of one to ninety-nine;

(b) Fiscal specialist 2, classification 66532, for facilities with a combined bed total of one hundred to one hundred ninety-nine;

(c) Fiscal officer 1, classification 66535, for facilities with a combined bed total of two hundred to two hundred ninety-nine;

(d) Fiscal officer 2, classification 66536, for facilities with a combined bed total of three hundred to five hundred ninety-nine;

(e) Fiscal officer 3, classification 66537, for facilities with a combined bed total of six hundred to one thousand one hundred ninety-nine; or

(f) Fiscal officer 4, classification 66538, for facilities with a combined bed total of one thousand two hundred or more.

(4) Board secretary/member

(a) Administrative professional 1, classification 16871, for facilities with a combined bed total of one to ninety-nine;

(b) Office manager, classification 16821, for facilities with a combined bed total of one hundred to one hundred ninety-nine;

(c) Administrative professional 4, classification 16874, for facilities with a combined bed total of two hundred to two hundred ninety-nine;

(d) Program administrator 2, classification 63123, for facilities with a combined bed total of three hundred to five hundred ninety-nine;

(e) Board/commission secretary 1, classification 62111, for facilities with a combined bed total of six hundred to one thousand one hundred ninety-nine; or

(f) Board/commission secretary 2, classification 62112, for facilities with a combined bed total of one thousand two hundred or more.

(5) For those owners and relatives of owners who serve the ICFIID in the capacity of a corporate officer, proprietor, or partner as specified in paragraphs (C)(1) to (C)(4) of this rule, the formula for determining the compensation cost limits is as follows:

(a) The civil service equivalent hourly rate as published by the Ohio department of administrative services for those positions specified in paragraphs (C)(1) to (C)(4) of this rule will be multiplied by two thousand eighty hours to arrive at an annual salary screen for each step in the position. If the civil service equivalent hourly rate changes during the reporting period, the civil service equivalent hourly rate will be the hourly rate that is in effect at the end of the cost reporting period.

(b) The appropriate job step within those civil service classifications as specified in paragraphs (C)(1) to (C)(4) of this rule will be based upon the owner's years of service in the health care field plus one.

(D) Determining reasonable costs and disallowances

Reasonable costs for compensation and compensation disallowances for owners and relatives of owners are the ICFIID's desk-reviewed, actual, allowable costs reported on schedule C-2 of the cost report subject to the applicable compensation cost limits and audit by the department. For each owner or relative of an owner that has reported compensation on schedule C-2 of the cost report, the medicaid information technology system will perform the following steps.

(1) Calculate the "time slice" for each owner and relative of an owner, which is defined as either:

(a) When there is no overlap of an employment period for an owner or relative of an owner working in a related ICFIID and the functions have the same position number, the number of days employed; or

(b) When there is an overlap of an employment period for an owner or relative of an owner working in a related ICFIID and the functions have the same position number:

(i) The number of days employed for the overlap of an employment period when the owner or relative of an owner is working in the related ICFIID during the same period of time; plus

(ii) The number of days employed preceding the overlapping employment period; plus

(iii) The number of days employed subsequent to the overlapping employment period.

(2) For each time slice of an owner or relative of an owner, calculate the following:

(a) Acquire the number of certified beds for the ICFIID as of the end of the cost reporting period from schedule A, line 2, column 1 of the cost report.

(b) Acquire the number of certified beds for related facilities that the owner or relative of an owner worked in during the time slice, as of the end of the cost reporting period.

(c) Calculate the total number of certified beds by adding the number of certified beds for the ICFIID as determined in accordance with paragraph (D)(2)(a) of this rule and the number of certified beds for any related facilities that the owner or relative of an owner worked in as determined in accordance with paragraph (D)(2)(a) of this rule.

(d) For an owner or relative of an owner who received compensation as a corporate officer, acquire the appropriate corporate duty job step as calculated in accordance with paragraph (C)(5)(b) of this rule.

(e) Determine the applicable compensation cost limit based on the position the owner or relative of an owner worked as follows:

(i) For an owner or relative of an owner who performs duties that are included on attachment 6 of the cost report, acquire the appropriate compensation cost limit as calculated in accordance with paragraph (B)(2)(d) of this rule subject to the following criteria:

(a) Compensation is allowable only for duties performed by an owner or relative of an owner which otherwise would require the employment of another person; and

(b) In order to qualify as a supervisor for positions listed on attachment 6 of the cost report, a supervisor must supervise at least two persons in an ICFIID with fifty or more beds. In an ICFIID with fewer than fifty beds, a supervisor may supervise one person.

(ii) For an owner or relative of an owner who perform duties which otherwise would have required the employment of another person and received compensation as a corporate officer, acquire the appropriate compensation cost limit as calculated in accordance with paragraph (C)(5) of this rule.

(iii) For purposes of determining the compensation cost limits, an owner or relative of an owner is overtime exempt. There shall be no upward adjustment to the applicable compensation cost limit to accommodate circumstances where such persons work in excess of forty hours per week.

(f) Calculate the total number of days employed for each owner or relative of an owner by subtracting the beginning date from the ending date for each time slice and adding one.

(g) Determine the total days in the calendar year.

(h) Calculate the per cent of days allowed by dividing the number of days in the time slice as calculated in accordance with paragraph (D)(2)(f) of this rule by the total days in the calendar year as determined in accordance with paragraph (D)(2)(g) of this rule.

(i) Calculate the time slice adjusted compensation cost limit by multiplying the per cent of days allowed as calculated in accordance with paragraph (D)(2)(h) of this rule by the adjusted compensation as calculated in accordance with paragraph (D)(2)(e) of this rule.

(j) Acquire the weekly hours in the time slice for the appropriate time period from schedule C-2 of the cost report.

(k) Acquire the related weekly hours in the time slice for the appropriate time period from the related ICFIID's schedule C-2 of the cost report.

(l) Calculate the total weekly hours in the time slice by adding the weekly hours in the time slice as determined in accordance with paragraph (D)(2)(j) of this rule and the related weekly hours in the time slice as determined in accordance with paragraph (D)(2)(k) of this rule.

(m) Calculate the maximum weekly hours:

(i) If the total weekly hours in the time slice as calculated in accordance with paragraph (D)(2)(l) of this rule is less than thirty-five hours per week then the maximum weekly hours in the time slice is forty; or

(ii) If the total weekly hours in the time slice as calculated in accordance with paragraph (D)(2)(l) of this rule is greater than or equal to thirty-five hours per week then the maximum weekly hours in the time slice is the total weekly hours in the time slice.

(n) Calculate the hours allocation percentage by dividing the weekly hours in the time slice as calculated in accordance with paragraph (D)(2)(j) of this rule by the maximum weekly hours as calculated in accordance with paragraph (D)(2)(m) of this rule.

(o) Calculate the final time slice adjusted compensation cost limit by multiplying the time slice adjusted compensation cost limit as calculated in accordance with paragraph (D)(2)(i) of this rule by the hours allocation percentage as calculated in accordance with paragraph (D)(2)(n) of this rule.

(p) Calculate a daily salary amount for each owner and relative of an owner by dividing the compensation amount by the number of days employed as reported on schedule C-2 of the cost report. For each time slice, calculate the prorated amount for each owner and relative of an owner by multiplying the daily salary amount for each owner and relative of an owner by the number of days in the time slice as calculated in accordance with paragraph (D)(2)(f) of this rule.

(q) Calculate the compensation disallowance for each owner and relative of an owner by subtracting the final time slice adjusted compensation cost limit as calculated in accordance with paragraph (D)(2)(o) of this rule from the prorated amount for each owner and relative of an owner as calculated in accordance with paragraph (D)(2)(p) of this rule. The result cannot be less than zero.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03
Five Year Review Date: 12/16/2024
Prior Effective Dates: 1/10/2013
Rule 5123-7-22 | Intermediate care facilities for individuals with intellectual disabilities - compensation cost limits for administrators who are not owners or relatives of owners.
 

(A) Purpose

This rule establishes limits, applicable to the cost report of an intermediate care facility for individuals with intellectual disabilities (ICFIID), for the amount of compensation that may be claimed for administrators of the ICFIID who are not owners or relatives of owners.

(B) Calculating compensation cost limits

Compensation cost limits for administrators shall be based upon compensation costs for administrators who are not owners or relatives of owners, as reported on the ICFIID's cost report for the calendar year preceding the fiscal year in which the rate is paid. The compensation cost limits for administrators, excluding owners and relatives of owners who are administrators, are calculated as follows:

(1) The compensation cost limits for administrators are calculated from:

(a) Cost reports with a December thirty-first end date; and

(b) Desk-reviewed and preliminarily determined to be allowable costs.

(2) For each administrator, calculate the hourly rate from schedule C-1 of the cost report as follows:

(a) Calculate the number of days employed by subtracting the employment period beginning date from the employment period ending date. Add one day to the number of days calculated to account for total days worked as reported on the cost report;

(b) Calculate the number of weeks worked by dividing the number of days employed by seven as calculated in accordance with paragraph (B)(2)(a) of this rule;

(c) Calculate the weekly compensation amount by dividing the compensation amount as reported on the cost report by the number of weeks worked as calculated in accordance with paragraph (B)(2)(b) of this rule; and

(d) Calculate the hourly rate by dividing the weekly compensation amount as calculated in accordance with paragraph (B)(2)(c) of this rule by the weekly hours as reported on the cost report.

(3) Exclude any administrator's hourly rate as calculated in accordance with paragraph (B)(2) of this rule that is less than the federal minimum wage rate in effect at the end of the cost reporting period.

(4) Excluding administrators described in paragraph (B)(3) of this rule, calculate the average annual administrator salary for each facility from schedule C-1 of the cost report as follows:

(a) For each administrator, calculate the hours worked by multiplying the weekly hours as reported on the cost report by the number of days employed as calculated in accordance with paragraph (B)(2)(a) of this rule;

(b) For all administrators as reported for each ICFIID, total the following:

(i) Number of days employed as calculated in accordance with paragraph (B)(2)(a) of this rule;

(ii) Compensation amounts as reported on the cost report; and

(iii) Hours worked as calculated in accordance with paragraph (B)(4)(a) of this rule;

(c) Calculate a weighted facility average weekly hours by dividing the sum of the weighted weekly hours as calculated in accordance with paragraph (B)(4)(b)(iii) of this rule by the total number of days employed as calculated in accordance with paragraph (B)(4)(b)(i) of this rule;

(d) Calculate the weighted facility compensation amount:

(i) If the weighted facility average weekly hours as calculated in accordance with paragraph (B)(4)(c) of this rule is less than thirty-five hours per week, multiply the total compensation amount as calculated in accordance with paragraph (B)(4)(b)(ii) of this rule by forty; or

(ii) If the weighted facility average weekly hours as calculated in accordance with paragraph (B)(4)(c) of this rule is thirty-five hours or more per week, multiply the total compensation amount as calculated in accordance with paragraph (B)(4)(b)(ii) of this rule by the weighted facility average weekly hours as calculated in accordance with paragraph (B)(4)(c) of this rule;

(e) Calculate the total salary per year by dividing the weighted facility compensation amount as calculated in accordance with paragraph (B)(4)(d) of this rule by the weighted facility average weekly hours as calculated in accordance with paragraph (B)(4)(c) of this rule; and

(f) Calculate the average annual administrator salary by multiplying the total salary per year as calculated in accordance with paragraph (B)(4)(e) of this rule by the number of days in a calendar year and dividing the product by the total number of days employed as calculated in accordance with paragraph (B)(4)(b)(i) of this rule.

(5) Group the average annual administrator salary for each ICFIID calculated in accordance with paragraph (B)(4)(f) of this rule into the following bed size categories based on certified beds at the end of the cost reporting period:

(a) One to forty-nine;

(b) Fifty to ninety-nine; or

(c) One hundred or more.

(6) For each bed size category in accordance with paragraph (B)(5) of this rule, calculate the compensation cost limit by summing the average annual administrator salary as calculated in accordance with paragraph (B)(4)(f) of this rule and dividing the total sum of all average annual administrator salary by the number of records summed.

(C) Determining reasonable costs and disallowances

Reasonable costs for compensation and compensation disallowances for administrators are the ICFIID's desk-reviewed, actual, allowable costs reported on schedule C-1 of the cost report subject to the applicable compensation cost limits and audit by the department.

(1) For each administrator that has reported compensation on schedule C-1 of the cost report, the medicaid information technology system shall perform the following steps:

(a) Calculate the "time slice" for each administrator, which is defined as either:

(i) When there is no overlap of an employment period for an administrator working in a related ICFIID, the number of days employed; or

(ii) When there is an overlap of an employment period for an administrator working in a related ICFIID;

(a) The number of days employed for the overlap of an employment period when the administrator is working in the related ICFIID during the same period of time; plus

(b) The number of days employed preceding the overlapping employment period; plus

(c) The number of days employed subsequent to the overlapping employment period.

(b) For each time slice of an administrator, calculate the following:

(i) Acquire the number of certified beds for the ICFIID as of the end of the cost reporting period from schedule A, line 2, column 1 of the cost report.

(ii) Acquire the number of certified beds for related facilities that the administrator worked in during the time slice as of the end of the cost reporting period.

(iii) Calculate the total number of certified beds by adding the number of certified beds for the ICFIID as determined in accordance with paragraph (C)(1)(b)(i) of this rule and the number of certified beds for any related facilities that the administrator worked in as determined in accordance with paragraph (C)(1)(b)(ii) of this rule.

(iv) Acquire the appropriate compensation cost limit as follows:

(a) If the administrator does not work in four or more related facilities, use the total number of certified beds determined in accordance with paragraph (C)(1)(b)(ii) of this rule to determine the appropriate compensation cost limit determined in accordance with paragraph (B)(6) of this rule; or

(b) If the administrator works in four or more related facilities, the compensation cost limit is the maximum for the bed size category determined in accordance with paragraph (B)(6) of this rule.

(v) Acquire the allowance percentage from schedule C-1 of the cost report which shall not exceed one hundred-fifty per cent.

(vi) Calculate the adjusted compensation cost limit by multiplying the compensation cost limit determined in accordance with paragraph (C)(1)(b)(iv) of this rule by the allowance percentage determined in accordance with paragraph (C)(1)(b)(v) of this rule.

(vii) Calculate the total number of days employed for each administrator by subtracting the beginning date from the ending date for each time slice and adding one.

(viii) Determine the total days in the calendar year.

(ix) Calculate the per cent of days allowed by dividing the number of days in the time slice as calculated in accordance with paragraph (C)(1)(b)(vii) of this rule by the total days in the calendar year as determined in accordance with paragraph (C)(1)(b)(viii) of this rule.

(x) Calculate the time slice adjusted compensation cost limit by multiplying the per cent of days allowed as calculated in accordance with paragraph (C)(1)(b)(ix) of this rule by the adjusted compensation as calculated in accordance with paragraph (C)(1)(b)(vi) of this rule.

(xi) Acquire the weekly hours in the time slice for the appropriate time period from schedule C-1 of the cost report.

(xii) Acquire the related weekly hours in the time slice for the appropriate time period from the related ICFIID's schedule C-1 of the cost report.

(xiii) Calculate the total weekly hours in the time slice by adding the weekly hours in the time slice as determined in accordance with paragraph (C)(1)(b)(xi) of this rule and the related weekly hours in the time slice as determined in accordance with paragraph (C)(1)(b)(xii) of this rule.

(xiv) Calculate the maximum weekly hours:

(a) If the total weekly hours in the time slice as calculated in accordance with paragraph (C)(1)(b)(xiii) of this rule is less than thirty-five hours per week, the maximum weekly hours in the time slice is forty; or

(b) If the total weekly hours in the time slice as calculated in accordance with paragraph (C)(1)(b)(xiii) of this rule is greater than or equal to thirty-five hours per week, the maximum weekly hours in the time slice is the total weekly hours in the time slice.

(xv) Calculate the hours allocation percentage by dividing the weekly hours in the time slice as calculated in accordance with paragraph (C)(1)(b)(xi) of this rule by the maximum weekly hours as calculated in accordance with paragraph (C)(1)(b)(xiv) of this rule.

(xvi) Calculate the final time slice adjusted compensation cost limit by multiplying the time slice adjusted compensation cost limit as calculated in accordance with paragraph (C)(1)(b)(x) of this rule by the hours allocation percentage as calculated in accordance with paragraph (C)(1)(b)(xv) of this rule.

(xvii) Calculate a daily salary amount for each administrator by dividing the compensation amount by the number of days employed as reported on schedule C-1 of the cost report. For each time slice, calculate the prorated administrator compensation amount by multiplying the daily salary amount for each administrator by the number of days employed in each time slice as calculated in accordance with paragraph (C)(1)(b)(vii) of this rule.

(xviii) Calculate the administrator compensation disallowance by subtracting the final time slice adjusted compensation cost limit as calculated in accordance with paragraph (C)(1)(b)(xvi) of this rule from the adjusted prorated administrator compensation amount as calculated in accordance with paragraph (C)(1)(b)(xvii) of this rule. The result cannot be less than zero.

(xix) Calculate the final adjusted prorated administrator compensation amount by subtracting the administrator compensation disallowance as calculated in accordance with paragraph (C)(1)(b)(xviii) of this rule from the adjusted prorated administrator compensation amount as calculated in accordance with paragraph (C)(1)(b)(xvii) of this rule.

(2) For each ICFIID, determine the overall facility administrator aggregate compensation disallowance for reporting costs in excess of the adjusted compensation cost limit as follows:

(a) Acquire the number of certified beds for the ICFIID as of the end of the cost reporting period from schedule A, line 2, column 1 of the cost report.

(b) Acquire the appropriate compensation cost limit for the bed size category using the total number of certified beds determined in accordance with paragraph (C)(2)(a) of this rule and the compensation cost limit determined in accordance with paragraph (B)(6) of this rule.

(c) Establish the allowance percentage as one hundred-fifty per cent.

(d) Calculate the adjusted compensation cost limit by multiplying the compensation cost limit determined in accordance with paragraph (C)(2)(b) of this rule by the allowance percentage determined in accordance with paragraph (C)(2)(c) of this rule.

(e) Calculate the total administrator allowable compensation by summing the compensation reported on schedule C-1 of the cost report for all administrators and subtracting any disallowances calculated in accordance with paragraph (C)(1)(b)(xviii) of this rule.

(f) Calculate the overall facility administrator aggregate compensation disallowance by subtracting the adjusted compensation cost limit as calculated in accordance with paragraph (C)(2)(d) of this rule from the total administrator allowable compensation as calculated in accordance with paragraph (C)(2)(e) of this rule. The result cannot be less than zero.

(D) Administrators serving in direct care positions

(1) If an administrator works in one or more of the following direct care cost center positions, the compensation earned for performing such duties may be expensed directly to the direct care cost center.

(a) Medical director;

(b) Director of nursing;

(c) Activities director;

(d) Registered nurse;

(e) Licensed practical nurse;

(f) Recreational therapist;

(g) Psychologist;

(h) Respiratory therapist;

(i) Qualified intellectual disability professional;

(j) Licensed social worker/counselor;

(k) Chaplain;

(l) Charge nurse - registered nurse; or

(m) Charge nurse - licensed practical nurse.

(2) Compensation for an administrator performing a direct care cost center function is allowable only for duties which otherwise would require the employment of another person. The portion of the administrator's total compensation paid by the ICFIID that may be reported in the direct care cost center shall be determined by multiplying the total compensation by the percentage of time the administrator spends performing the direct care cost center duties.

(3) The ICFIID must maintain records documenting the allocation of the administrator's time to the direct care cost center duties. Time studies conducted in accordance with the centers for medicare and medicaid services publication 15-1, "Provider Reimbursement Manual" (revised January 2005), available at http://www.cms.hhs.gov/manuals, shall be considered sufficient documentation of the allocation of time. If the department finds that the ICFIID has not sufficiently documented the allocation of time, the cost associated with the undocumented time will be reclassified back to the indirect cost center.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03
Five Year Review Date: 12/16/2024
Rule 5123-7-23 | Intermediate care facilities for individuals with intellectual disabilities - method for establishing the other protected costs component of the prospective rate.
 

(A) Purpose

This rule sets forth the method for establishing the other protected costs component of the prospective rate paid to an intermediate care facility for individuals with intellectual disabilities (ICFIID).

(B) Calculation of per diem rate

Each eligible ICFIID shall be paid a per diem for each resident for other protected costs. This component of the rate will be established prospectively each fiscal year. This per diem shall be calculated by dividing the desk-reviewed, actual, allowable other protected costs total except for the franchise permit fee (account number 6091) by the inpatient days. This information will come from the year-end cost report preceding the fiscal year in which the rate will be paid. This per diem will then be inflated by the estimated inflation rate as calculated in accordance with paragraph (C) of this rule and added to the per diem for the franchise permit fee as calculated in accordance with paragraph (D) of this rule to determine the total other protected costs component of the prospective rate.

(C) Estimated inflation rate

The department shall estimate the rate of inflation for the eighteen-month period using the consumer price index for all urban consumers for nonprescription drugs and the consumer price index for all urban consumers for medical supplies, as published by the United States bureau of labor statistics. The estimated inflation rate is calculated by taking the value of the indexes as of the thirty-first day of December in the fiscal year the rate will be paid, divided by the value of the indexes as of the first day of July in the immediately preceding calendar year. 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 fiscal year.

(D) Franchise permit fee

Notwithstanding the method for reimbursement for other protected costs as set forth in rule 5123-7-12 of the Administrative Code, the franchise permit fee rate in the amount equal to the assessment specified in section 5168.61 of the Revised Code will be included in the other protected costs center per diem rate for each ICFIID subject to the franchise permit fee assessment as specified in section 5168.61 of the Revised Code. The ICFIID will not receive reimbursement for the franchise permit fee if there is no assessment. The franchise permit fee rate is not subject to the inflation factor that is allowed for costs reported in the other protected costs center in accordance with paragraph (C) of this rule.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03, 5168.61
Five Year Review Date: 12/16/2024
Rule 5123-7-24 | Intermediate care facilities for individuals with intellectual disabilities - costs of ownership payment.
 

(A) Purpose

This rule sets forth conditions necessary for an intermediate care facility for individuals with intellectual disabilities (ICFIID) to receive a costs of ownership payment. This rule applies only to the capital rate calculation prescribed in section 5124.171 of the Revised Code.

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Costs of ownership" means the actual expense incurred for:

(a) Depreciation and interest on any items capitalized including:

(i) Buildings;

(ii) Building improvements;

(iii) Equipment;

(iv) Extensive renovation;

(v) Transportation equipment; and

(vi) Replacement beds.

(b) Amortization and interest on land improvements and leasehold improvements.

(c) Amortization of financing costs.

(d) Lease and rent of land, building, and equipment.

(2) "Extensive renovation" means a renovation that costs more than sixty-five per cent and no more than eighty-five per cent of the cost of constructing a new bed and that extends the useful life of the assets for at least ten years. To calculate the per-bed cost of a renovation project for purposes of determining whether it is an extensive renovation, the allowable cost of the project shall be divided by the number of beds in the facility certified for participation in the medicaid program, even if the project does not affect all medicaid-certified beds. Allowable extensive renovations are considered an integral part of costs of ownership.

(a) The cost of constructing a new bed shall be considered to be forty thousand dollars, adjusted for inflation from January 1, 1993 to the end of the calendar year during which the renovation is completed 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.

(b) The department 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) "Nonextensive renovation" has the same meaning as in rule 5123-7-25 of the Administrative Code.

(4) "Replacement beds" are beds which are relocated to a new building or portion of a building attached to and/or constructed outside of the original licensed structure of an ICFIID. Replacement beds may originate from within the licensed structure of an ICFIID or from another ICFIID. Replacement beds are eligible for the costs of ownership efficiency incentive ceiling which corresponds to the period in which the beds were replaced.

(C) Costs of ownership payment

(1) For an ICFIID that has dates of licensure or that has been granted project authorization by the department on or after July 1, 1993, for which substantial commitments of funds were not made before July 1, 1993, costs of ownership payments shall not exceed the ceilings established in section 5124.171 of the Revised Code, if the department gives prior approval for construction of the ICFIID.

(a) Prior to commencement of construction, the provider must submit a request in writing to the department. The request shall include:

(i) The projected completion date for the new ICFIID.

(ii) A projected budget for the new ICFIID that includes a projected three-month cost report that contains all cost centers and inpatient days so that an overall rate can be calculated. For beds relocated from an existing ICFIID, the same information must be received for the existing ICFIID and the ICFIID to which the beds are to be relocated.

(b) The department shall review the request and the projected budget, comparing the projected cost per diem to the rate currently associated with the beds for cost neutrality to the Ohio medicaid program. Cost neutrality shall be evaluated across beds transferred to the new ICFIID and the beds remaining in the existing ICFIID.

(c) Approval for the increased costs of ownership payments shall be granted contingent upon the receipt by the department of the provider's filed actual cost report for the first three months of operation confirming cost neutrality to the Ohio medicaid program. Until a final determination is made by the department with regard to the request for increased costs of ownership payments, the lower costs of ownership ceiling shall be effective.

(d) Written approval or denial of the preliminary request shall be made by the department within sixty calendar days of the date the initial request was made and the required documentation was received. Written documentation of the final determination shall be provided by the department within sixty calendar days from the date the new ICFIID's actual three-month cost report is received.

(e) If the project continues to satisfy the cost neutrality standard, the higher costs of ownership ceiling shall be implemented retroactively to the first day the new ICFIID's provider agreement was effective. If the request is denied, the provider shall continue to receive the lower costs of ownership ceiling.

(2) An ICFIID that completes extensive renovations shall receive a per diem for costs of ownership based upon the costs as specified in paragraph (C)(1) of this rule.

(a) The date of licensure for an extensively renovated ICFIID shall be considered to be the date of completion of the extensive renovation.

(b) The current limits as calculated in accordance with section 5124.171 of the Revised Code shall be assigned to the extensively renovated ICFIID using the date of licensure.

(c) An extensively renovated ICFIID that obtains new ceilings in accordance with this rule, shall not be permitted any reimbursement for nonextensive renovation under rule 5123-7-25 of the Administrative Code made prior to the extensive renovation project which resulted in the new ceilings. Thereafter, the cost and accumulated depreciation of the nonextensive renovation shall be included in costs of ownership.

(d) An extensively renovated ICFIID shall not be permitted to receive any reimbursement for nonextensive renovation under rule 5123-7-25 of the Administrative Code for a period of five years after the completion of the extensive renovations, with the exception of those nonextensive renovation projects necessary to meet the requirements of federal, state, or local statutes, ordinances, rules, or policies.

Supplemental Information

Authorized By: 5124.03, 5123.04
Amplifies: 5123.04, 5124.171, 5124.03
Five Year Review Date: 7/8/2023
Prior Effective Dates: 1/10/2013
Rule 5123-7-25 | Intermediate care facilities for individuals with intellectual disabilities - nonextensive renovation.
 

(A) Purpose

This rule defines nonextensive renovation and sets forth the process for calculating the per-bed cost of a nonextensive renovation project at an intermediate care facility for individuals with intellectual disabilities (ICFIID).

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Extensive renovation" has the same meaning as in rule 5123-7-24 of the Administrative Code.

(2) "Nonextensive renovation" means a project, approved by the department prior to the effective date of this rule in accordance with rule 5123:2-7-25 of the Administrative Code as it existed on the day immediately prior to the effective date of this rule, for the betterment, improvement, or restoration of an ICFIID beyond its current functional capacity through a structural change that costs at least five hundred dollars per bed. To calculate the per-bed cost of a renovation project for purposes of determining whether it is a nonextensive renovation, the allowable cost of the project shall be divided by the number of beds in the ICFIID certified for participation in the medicaid program, even if the project does not affect all medicaid-certified beds. "Nonextensive renovation" may include betterment, improvement, restoration, or replacement of assets that are affixed to the building and have a useful life of at least five years. "Nonextensive renovation" may include costs that otherwise would be considered maintenance and repair expenses if they are included as part of the nonextensive renovation project and are an integral part of the structural change that makes up the nonextensive renovation project. "Nonextensive renovation" does not mean construction of additional space for beds that will be added to an ICFIID's licensed or certified capacity. Allowable nonextensive renovation projects are not considered costs of ownership.

(C) Determining the cost of nonextensive renovation

(1) The desk-reviewed actual, allowable, per diem cost of nonextensive renovation is based upon certified beds for property costs and assets affixed to the building for the calendar year preceding the fiscal year in which the rate will be paid. The desk-reviewed actual, allowable, per diem cost of nonextensive renovation includes:

(a) The cost of purchasing or acquiring capital assets that meet the requirements of nonextensive renovation in accordance with this rule which includes:

(i) Depreciation expense for the cost of buildings equal to the actual cost depreciated in accordance with rule 5123:2-7-18 of the Administrative Code for nonextensive renovation. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(ii) Depreciation expense for major components of property and fixed equipment equal to the actual cost depreciated in accordance with rule 5123:2-7-18 of the Administrative Code for nonextensive renovation. The provider is not to change the accumulated depreciation that has been previously reported. This accumulated depreciation will be carried forward as previously reported and audited. The current depreciation will then be added to accumulated depreciation as recognized.

(iii) Interest expense incurred on money borrowed for capital assets that qualify for nonextensive renovation.

(iv) Depreciation expense for costs paid or reimbursed by any government agency, if that part of the prospective per diem rate is used to reimburse the government agency and a loan provides for repayment over a time-limited period. These capital assets must qualify for nonextensive renovation.

(v) Amortization expense of financing costs.

(b) The cost of nonextensive renovation directly related to the amortization of leasehold improvements that meet the criteria for nonextensive renovation in accordance with this rule. These costs shall be expensed over the lesser of the remaining life of the lease, but not less than five years, or the useful life of the improvement as specified in rule 5123:2-7-18 of the Administrative Code. If the useful life of the improvement is less than five years, it may be amortized over its useful life. Options on leases will not be considered. Lessees who report leasehold improvements and who leave the program before the minimum amortization period is complete will not receive reimbursement for the balance of unamortized costs.

(2) The cost of nonextensive renovation directly attributable to the purchase of property and equipment costs from one related party to another through common ownership or control shall be based upon the lesser of the actual purchase of property and equipment costs or the actual costs of the related party.

(D) Criteria for treatment as a nonextensive renovation

(1) The following shall apply in order to determine if a project qualifies for treatment as a nonextensive renovation.

(a) The project meets the definition of nonextensive renovation set forth in paragraph (B)(2) of this rule.

(b) The project does not increase the number of licensed beds.

(c) If the ICFIID relocates beds within the current structure of the building, the construction for the relocated beds shall be considered a nonextensive renovation if it meets the other criteria specified in this rule unless the project meets the requirements of extensive renovation.

(d) The ICFIID obtained approval of the project as a nonextensive renovation from the department prior to the effective date of this rule.

(e) The ICFIID has satisfied all requirements for notice to the department upon completion of the project as set forth in paragraph (F) of this rule.

(2) A nonextensive renovation project shall be started within six months after the date the department grants approval. For the purposes of this rule, "started" means the physical work has begun on the project at the site of the ICFIID. Preliminary work such as planning, agency approval, feasibility surveys, and architectural drawings are not considered "started."

(3) A nonextensive renovation project shall be completed within eighteen months after it is started. The total cost of all portions of the nonextensive renovation project completed within eighteen months after it is started must satisfy the per-bed cost requirement set forth in paragraph (B)(2) of this rule.

(4) Failure to satisfy the conditions set forth in paragraphs (D)(1) to (D)(3) of this rule shall result in the costs of the project being reported as costs of ownership in lieu of nonextensive renovation.

(E) Additional notice requirements

Additional notice to the department is required during the course of the construction of the approved nonextensive renovation if:

(1) The completion of the nonextensive renovation project is delayed or accelerated by more than four months from the estimated date of completion.

(2) The actual cost of construction exceeds the approved cost by the greater of ten per cent or two thousand dollars.

(a) Upon receiving notice of the increase in the cost of construction, the department may approve the additional project costs for inclusion as a nonextensive renovation. In reviewing a project for approval under this paragraph, the department shall apply the criteria specified in paragraph (D) of this rule.

(b) If the department does not approve the additional cost of construction, expenses related to all costs of construction in excess of the approved amount shall be reported as costs of ownership.

(c) If the provider fails to provide notice to the department of the increase in the cost of construction, expenses related to all costs of construction in excess of the approved amount shall be reported as costs of ownership.

(3) The actual amount financed exceeds the approved amount financed by the greater of ten per cent or two thousand dollars.

(a) Upon receiving notice of the increase in the amount financed, the department may approve the increase in the amount financed for inclusion as a nonextensive renovation. In reviewing a project for approval under this paragraph, the department shall apply the criteria specified in paragraph (D) of this rule.

(b) If the department does not approve the additional amount financed, interest expense related to all amounts financed in excess of the approved amount shall be reported as costs of ownership.

(c) If the provider fails to provide notice to the department of the increase in the amount financed, interest expense related to all amounts financed in excess of the approved amount shall be reported as costs of ownership.

(4) The actual interest rate exceeds the projected interest rate by two or more percentage points.

(a) Upon receiving notice of the increase in the interest rate, the department may approve the interest expense associated with the increased interest rate for inclusion as a nonextensive renovation. In reviewing a project for approval under this paragraph, the department shall apply the criteria specified in paragraph (D) of this rule.

(b) If the department does not approve the increased interest rate, the interest expense associated with the incremental increase in the approved interest rate shall be reported as costs of ownership.

(c) If the provider fails to provide notice to the department of the increase in the interest rate, the interest expense associated with the incremental increase in the approved interest rate shall be reported as costs of ownership.

(5) There is any increase or decrease in the scope of the nonextensive renovation project.

(a) Upon receiving notice of the change in the scope of the nonextensive renovation project, the department may approve the project as revised if the change in scope bears a reasonable relationship to the approved nonextensive renovation project.

(b) If the department does not approve the project as revised, the additional costs associated with the change in scope shall be reported as costs of ownership.

(c) If the provider fails to provide notice to the department of the change in the scope of the project, the additional costs associated with the change in scope shall be reported as costs of ownership.

(6) Any change of cost causes the project to exceed the threshold for being considered an extensive renovation or to fall below the threshold for being considered a nonextensive renovation.

(F) Reporting a nonextensive renovation project on the cost report

(1) Before a nonextensive renovation or portion thereof can be reported on the cost report, notice of completion must be submitted to the department. The notice of completion shall include:

(a) The date the project or portion thereof was placed in service;

(b) Detailed depreciation and amortization schedules and a narrative explanation of any material differences between the expenses stated on the schedules and the estimated costs submitted for the project and prior-approved by the department; and

(c) A detailed reconciliation of actual financing cost to the projected financing cost in the request for approval of a nonextensive renovation.

(2) A nonextensive renovation may be reported on the cost report as each portion of the project is placed into service as long as the anticipated completion of the portions of the project is still within the period set forth in paragraphs (D)(2) and (D)(3) of this rule and in the aggregate satisfy the per-bed cost requirement set forth in paragraph (B)(2) of this rule.

(3) If the total cost of all the portions of the entire project that have been placed into service within the period set forth in paragraphs (D)(2) and (D)(3) of this rule do not satisfy the per-bed cost requirement set forth in paragraph (B)(2) of this rule, the costs and related expenses for all the portions of the project that have been reported as a nonextensive renovation shall be reported as costs of ownership.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03, 5124.171
Five Year Review Date: 7/8/2023
Prior Effective Dates: 1/10/2013
Rule 5123-7-27 | Intermediate care facilities for individuals with intellectual disabilities - request for rate reconsideration.
 

(A) Purpose

This rule establishes a process for an intermediate care facility for individuals with intellectual disabilities (ICFIID) or a group or association of ICFIID providers to request reconsideration of an ICFIID's per diem payment rate pursuant to section 5124.38 of the Revised Code.

(B) Submission of request

(1) In addition to the circumstances referenced in section 5124.38 of the Revised Code, reconsideration of an ICFIID's per diem payment rate may be requested:

(a) On the basis of a possible error in the calculation of the rate; or

(b) Upon direct admission of a resident from a department-operated ICFIID, on the basis of extreme hardship on the admitting ICFIID.

(2) A request for rate reconsideration shall be submitted:

(a) In the case of a possible error in the calculation of the rate, within thirty calendar days after the later of the initial payment of the rate or the receipt of the rate-setting calculation.

(b) In the case of direct admission of a resident from a department-operated ICFIID, within ninety calendar days after admission.

(3) A request for rate reconsideration for items referenced in this rule or in section 5124.38 of the Revised Code shall be submitted in writing via email to cr-icf@dodd.ohio.gov.

(a) The request shall indicate the reason for rate reconsideration.

(b) In the case of a possible error in the calculation of the rate, the request shall include a detailed explanation of the possible error and the proposed corrected calculation and references to the relevant sections of the Revised Code and/or rules of the Administrative Code as appropriate.

(c) In the case of direct admission of a resident from a department-operated ICFIID, the request shall include a detailed summary of the facts supporting the request, including demonstration of the increased costs and the requested adjusted per diem rate.

(C) Consideration of the request

(1) The department shall respond in writing within sixty calendar days of receiving a written request for rate reconsideration. If the department requests additional information to determine whether a rate adjustment is warranted, the ICFIID shall respond in writing and provide additional supporting documentation within thirty calendar days of receipt of the request for additional information. The department shall respond in writing within sixty calendar days of receiving the additional information.

(2) If the department grants a rate adjustment due to an error in the calculation of the rate, the adjustment shall be implemented retroactively to the initial service date for which the rate is effective.

(3) If the department grants a rate adjustment due to direct admission of a resident from a department-operated ICFIID, the adjustment shall be implemented the first day of the first month the former resident of a department-operated ICFIID resides in the admitting ICFIID.

(a) The adjusted rate shall be time-limited to no longer than twelve consecutive months and may span fiscal years. There shall be no extensions granted beyond the initial twelve months. The rate adjustment shall be rescinded earlier than twelve months should the admitted former resident of a department-operated ICFIID permanently leave the ICFIID for any reason.

(b) The maximum amount available for each admitted former resident of a department-operated ICFIID shall be no more than fifty dollars per day, with the rate determined by dividing fifty dollars by the number of filled beds in the admitting ICFIID including the bed occupied by the former resident of a department-operated ICFIID. The resulting amount will be added to the ICFIID's per diem rate until the end of the state fiscal year.

(c) If the twelve consecutive months cross a state fiscal year, the calculation in paragraph (C)(3)(b) of this rule will be repeated at the beginning of the next state fiscal year and the adjusted per diem rate will remain in effect until the end of the twelfth consecutive month from the date the first adjusted per diem rate was applied.

(4) If the department grants a rate adjustment to an ICFIID that subsequently undergoes a change of operator, the adjusted rate shall remain in place as though a change of operator had not occurred.

(5) The department's decision at the conclusion of the rate reconsideration process shall not be subject to any administrative proceedings under Chapter 119. or any other provision of the Revised Code.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03, 5124.38
Five Year Review Date: 7/8/2023
Prior Effective Dates: 1/10/2013
Rule 5123-7-28 | Intermediate care facilities for individuals with intellectual disabilities - intensive behavioral support rate add-on.
 

(A) Purpose

This rule sets forth requirements for an intermediate care facility for individuals with intellectual disabilities (ICFIID) to receive a per diem rate add-on established pursuant to section 5124.26 of the Revised Code for providing short-term intensive behavioral support to youth with complex behavioral support needs in a discrete unit or building of six or fewer beds.

(B) Definitions

For the purposes of this rule, the following definitions apply:

(1) "Accredited college or university" means a college or university accredited by a national or regional association recognized by the secretary of the United States department of education or a foreign college or university of comparable standing.

(2) "Aftercare services" means individualized, intensive, post-discharge services driven by input from a youth and his or her team, provided by a discharging ICFIID to the youth and his or her family or other caregivers, as applicable.

(3) "Business day" means a day of the week, excluding Saturday, Sunday, or a legal holiday as defined in section 1.14 of the Revised Code.

(4) "County board" means a county board of developmental disabilities.

(5) "Follow-along services" means contact, engagement, and assistance provided by the department to support a youth who has been discharged from an ICFIID to ensure he or she makes a successful transition back into his or her home and community.

(6) "Intensive behavioral support rate add-on" means per diem reimbursement in the amount of three hundred dollars paid to an ICFIID that is approved by the department in accordance with this rule for serving a specific resident who is in middle to late childhood, generally age ten through seventeen, and who has complex behavioral support needs. The intensive behavioral support rate add-on is intended to compensate an ICFIID for the additional costs associated with serving a youth with complex behavioral support needs such as:

(a) Intensive and specialized therapies (e.g., occupational, physical, speech, audiology, and applied behavior analysis);

(b) Non-traditional therapies (e.g., art, music, and recreation);

(c) Higher staffing levels including one-to-one staffing;

(d) Specialized training for staff;

(e) Higher level and intensity of supervision;

(f) Intensive engagement with family or other caregivers; and

(g) Participating in the intensive behavioral support community of practice convened by the department.

(7) "Person-centered plan" means a written description of the services to be provided to a resident of an ICFIID that meets the requirements set forth in 42 C.F.R. 483.440(c) as in effect on the effective date of this rule for an individual program plan and the requirements for person-centered planning set forth in rule 5123:2-3-03 of the Administrative Code.

(8) "Psychiatrist" means a physician licensed in accordance with Chapter 4731. of the Revised Code to practice psychiatry.

(C) Approval to receive the intensive behavioral support rate add-on

There are two components of securing approval to receive the intensive behavioral support rate add-on:

(1) Facility eligibility

(a) An ICFIID that is interested in receiving the intensive behavioral support rate add-on for current or prospective residents may, when the department is seeking applications, complete and submit an application. The ICFIID will provide information requested by the department and may be subject to documentation reviews and on-site visits by department personnel as part of the application process.

(b) As part of its application, an ICFIID will submit a best practices protocol for providing intensive behavioral support which will be evaluated by the department to determine if it is acceptable.

(c) To obtain and maintain approval to receive the intensive behavioral support rate add-on, an ICFIID will:

(i) Enter into an agreement with the department for the provision of intensive behavioral support.

(ii) Agree to cooperate with the department's oversight of intensive behavioral support as described in paragraph (E) of this rule.

(d) An ICFIID whose license has been suspended and/or proposed for revocation by the department within the past twenty-four months is not eligible to receive the intensive behavioral support rate add-on.

(2) Specific youth served

(a) An ICFIID that has complied with the requirements and obtained approval in accordance with paragraph (C)(1) of this rule may request the intensive behavioral support rate add-on which may be available for serving a specific youth who is:

(i) Within middle to late childhood, generally age ten through seventeen.

(ii) Determined by the department, in collaboration with the youth's home county board, to need intensive behavioral support based on a comprehensive review of the youth. Referral of a youth to the department for a comprehensive review described in this paragraph may be initiated by the ICFIID or by another entity (such as a county board or the Ohio department of medicaid). The comprehensive review will include input from the youth and his or her team and consider:

(a) The youth's:

(i) Clinical diagnosis and history;

(ii) Current and past medications;

(iii) History of living arrangements (e.g., inside or outside family home, multiple settings, or out-of-state);

(iv) Educational history (e.g., previous educational programs, therapies, and services);

(v) Sensory integration and functioning (e.g., awareness of and response to touch, light, color, smell, taste, and texture);

(vi) Motor skills (e.g., sitting, standing, walking, running, climbing stairs, picking up items, and holding objects);

(vii) Cognitive abilities (e.g., maintaining attention, organizing self, recalling information, and connecting behavior with consequences);

(viii) Most successful and/or preferred learning style or modality;

(ix) Communication skills (e.g., level of speech and ability/method for expressing wants and needs);

(x) Emotional experience and functioning (e.g., history of trauma; description of the type and intensity of behaviors that present a danger to self or others; ability to adapt to change; and if or how the youth demonstrates anxiety, fear, or symptoms of depression);

(xi) Social experience and skills (e.g., making and keeping friends, being able to wait patiently for assistance or attention, and maintaining personal space);

(xii) Preferences and interests, including what is important to and important for the youth, as well as any skills the youth possesses that are not addressed in other areas; and

(xiii) Needs and strengths identified through administration of the "Child and Adolescent Needs and Strengths" decision-making tool.

(b) Positive supports and interventions that have been found effective in meeting the youth's needs (e.g., successful visual and environmental supports).

(c) Assistive technology that has been used or is currently used to support the youth.

(b) An ICFIID will electronically submit a request to secure approval to receive the intensive behavioral support rate add-on for serving a specific youth to the department.

(i) The department will determine whether the ICFIID will receive the intensive behavioral support rate add-on for serving a specific youth based on the information contained in the submitted request, the comprehensive review of the youth conducted in accordance with paragraph (C)(2)(a)(ii) of this rule, the services offered by the ICFIID, the residents currently served by the ICFIID, and other information deemed relevant by the department. The department will notify the ICFIID of its determination within fourteen calendar days after receipt of the comprehensive review and other relevant information.

(ii) The department may issue initial approval for the intensive behavioral support rate add-on to an ICFIID for serving a specific youth for a maximum period of one hundred eighty days.

(iii) The department may issue approval for continuation of the intensive behavioral support rate add-on beyond the previously approved period. To ensure continuity, an ICFIID will electronically submit a request at least thirty calendar days prior to the last day of the previously approved period. The department will make a determination based on the submitted request, reports regarding critical events and the status of the youth's progress, discharge planning options, assessments conducted by the department, and other information deemed relevant by the department. The department may approve continuation of the intensive behavioral support rate add-on for periods of up to one hundred eighty days per request.

(iv) The department will issue notice of determination, indicating approval or denial of the request for the intensive behavioral support rate add-on for serving a specific youth, to the ICFIID by electronic mail and provide a copy of the notice to the youth's home county board.

(a) When a request for the intensive behavioral support rate add-on is denied, the notice will specify the reason for denial.

(b) When a request for the intensive behavioral support rate add-on is approved, the notice will include an assigned approval number, the number of days for which the intensive behavioral support rate add-on is approved, and the date on which payment is approved to begin. The notice will also include the name, location, and phone number of the department staff member who is assigned to monitor the youth's progress at the ICFIID.

(D) Requirements for services provided

With regard to a youth for whom an ICFIID receives the intensive behavioral support rate add-on, the ICFIID shall:

(1) Serve the youth in a discrete unit or building where only residents age ten through seventeen reside and that has six or fewer beds.

(2) Provide the youth with his or her own bedroom which will not be shared by any other resident.

(3) Provide services in accordance with the ICFIID's best practices protocol for providing intensive behavioral support.

(4) Utilize trauma-informed approaches to care.

(5) Ensure that staff who supervise the day-to-day provision of services meet one of the following:

(a) Hold professional license or certification issued by the Ohio board of psychology; the state medical board of Ohio; or the Ohio counselor, social worker, and marriage and family therapist board;

(b) Hold a certificate to practice as a certified Ohio behavior analyst pursuant to section 4783.04 of the Revised Code; or

(c) Hold a bachelor's or graduate-level degree from an accredited college or university and have at least three years of paid full-time (or equivalent part-time) experience in developing and/or implementing behavioral support and/or risk reduction strategies or plans.

(6) Ensure that staff who supervise the day-to-day provision of services and staff who directly provide services successfully complete training in:

(a) Orientation to provision of intensive behavioral support, including the rights of persons with developmental disabilities set forth in section 5123.62 of the Revised Code and the requirements of rule 5123:2-2-06 of the Administrative Code;

(b) Accepted best practices and innovative approaches, as set forth in the ICFIID's best practices protocol for providing intensive behavioral support, to meet residents' needs;

(c) Department-provided training in comprehensive supports for youth with complex behavioral support needs; and

(d) The specific needs of, and supports to be provided to, each resident.

(7) Ensure that nursing services are available twenty-four hours per day.

(8) Ensure that psychiatric services are available twenty-four hours per day and that a psychiatrist reviews the youth's clinical status at least once every six months.

(9) Electronically submit notice to the department no later than by the close of the next business day when a youth experiences a significant change in status, including psychiatric hospitalization.

(10) Obtain the department's approval prior to initiating a transfer or termination of services in accordance with rule 5123:2-3-05 of the Administrative Code.

(11) Develop a comprehensive person-centered plan including a viable discharge plan, within thirty calendar days of a youth's admission that reflects:

(a) Ongoing collaboration with the youth's parent or guardian, as applicable, and home county board;

(b) Arrangement of school services for the youth;

(c) Identifying and accessing necessary supports and services to ensure the youth and the youth's family or other caregivers, as applicable, are successful; and

(d) Training the youth's family or other caregivers, as applicable, in techniques that are found effective for supporting the youth.

(12) On a weekly basis, complete progress notes which describe the youth's progress or lack of progress, significant changes in functioning, and recommendations for modification to the person-centered plan, if indicated.

(13) In collaboration with a youth's home county board and the department, provide three months of aftercare services upon the youth's discharge.

(E) Department oversight

(1) The department will oversee provision of intensive behavioral support to a youth for whom an ICFIID is receiving the intensive behavioral support rate add-on. Department oversight includes:

(a) Providing support to the ICFIID, the youth, and the youth's family or other caregivers to ensure the youth's needs are met as determined by the team;

(b) Facilitating collaboration between the ICFIID and the youth's home county board;

(c) Working closely with the ICFIID to discharge the youth as appropriate or as the youth approaches eighteen years of age; and

(d) Providing follow-along services for three years after the youth is discharged from the ICFIID.

(2) The department may withdraw approval of an ICFIID's facility-level eligibility to receive the intensive behavioral support rate add-on based on:

(a) The ICFIID's failure to provide services in accordance with this rule or its agreement with the department for provision of intensive behavioral support;

(b) A pattern of refusing to serve youth referred to the ICFIID by the department;

(c) A pattern of requests to involuntarily discharge youth for whom the ICFIID receives the intensive behavioral support rate add-on based on the ICFIID's inability to provide necessary services;

(d) The need to safeguard the health, safety, or wellbeing of residents or staff of the ICFIID; or

(e) The results of a compliance review of the ICFIID conducted in accordance with rule 5123:2-3-06 of the Administrative Code.

(3) The department will notify an ICFIID by certified mail of withdrawal of approval of the ICFIID's facility-level eligibility to receive the intensive behavioral support rate add-on no less than thirty calendar days in advance and assist the ICFIID and the home county board of an affected resident in securing alternative accommodations.

(F) Payment of the intensive behavioral support rate add-on

(1) The department may limit the number of intensive behavioral support rate add-ons that are available.

(2) The payment approval date for the intensive behavioral support rate add-on will be one of the following, but may not be earlier than the effective date of a youth's developmental disabilities level of care determination:

(a) For a youth admitted to an ICFIID on or after the effective date of this rule, the latter of the date of approval for payment of the intensive behavioral support rate add-on or the date of admission to the ICFIID; or

(b) For a youth admitted to an ICFIID prior to the effective date of this rule, the date of approval for payment of the intensive behavioral support rate add-on.

(3) The intensive behavioral support rate add-on will be billed and paid in addition to an ICFIID's typical per diem rate for a specific youth for whom the ICFIID has secured approval in accordance with paragraph (C)(2) of this rule.

(4) The intensive behavioral support rate add-on will be effective on the payment approval date determined in accordance with paragraph (F)(2) of this rule through the date authorized by the department in accordance with paragraph (C)(2)(b)(iv)(b) of this rule or until the date the youth no longer meets the criteria set forth in paragraph (C)(2)(a) of this rule.

(5) An ICFIID shall electronically submit notice to the department no later than by the close of the next business day when a youth no longer meets the criteria set forth in paragraph (C)(2)(a) of this rule.

(6) An ICFIID shall not bill the intensive behavioral support rate add-on for a youth who is using bed-hold days in accordance with rule 5123:2-7-08 of the Administrative Code.

(7) Payment of the intensive behavioral support rate add-on may be denied for any service not rendered in accordance with Chapters 5123-7, 5123:2-7, and 5160-3 of the Administrative Code.

Supplemental Information

Authorized By: 5123.04, 5124.03, 5124.26
Amplifies: 5124.26
Five Year Review Date: 9/18/2025
Rule 5123-7-30 | Intermediate care facilities for individuals with intellectual disabilities - exception review process for individual assessment form data.
 

(A) Purpose

This rule sets forth a process by which the department shall conduct exception reviews related to individual assessment form data submitted by an intermediate care facility for individuals with intellectual disabilities (ICFIID).

(B) Definitions

(1) "Annual facility average case mix score" has the same meaning as in rule 5123-7-20 of the Administrative Code.

(2) "Case mix score" has the same meaning as in rule 5123-7-20 of the Administrative Code.

(3) "Exception review" means a review conducted of an ICFIID by qualified intellectual disability professionals, registered nurses, or other licensed or certified health professionals employed by or under contract with the department for purposes of identifying inaccuracies related to the individual assessment form data submitted by the ICFIID in accordance with rule 5123-7-20 of the Administrative Code, which result in inaccurate case mix scores being used to calculate an ICFIID's direct care rate. Exception reviews shall be conducted before the annual rates are established pursuant to section 5124.15 of the Revised Code. Exception reviews shall be conducted in accordance with applicable provisions of the medicaid program.

(4) "Exception review tolerance level" means an acceptable level of variance in the calculation of the ICFIID's quarterly facility average case mix score. The variance is calculated as a percentage of the difference between the score based on exception review findings compared to the score based on the individual assessment form data submitted by the ICFIID for that quarter. The exception review tolerance level is a two per cent difference between the quarterly facility average case mix score based on exception review findings and the quarterly facility average case mix score based on individual assessment form data submitted by the ICFIID.

(5) "Individual assessment form" means the instrument used to assess the needs and circumstances of an individual with developmental disabilities for the purpose of calculating an ICFIID's direct care costs pursuant to sections 5124.195 to 5124.198 of the Revised Code.

(6) "Quarterly facility average case mix score" has the same meaning as in rule 5123-7-20 of the Administrative Code.

(7) "Resident assessment classification system" has the same meaning as in rule 5123-7-20 of the Administrative Code.

(C) Selection and review process

(1) The department shall select an ICFIID for exception review based on:

(a) The findings of a certification survey conducted by the Ohio department of health that may indicate that the ICFIID is not accurately assessing residents which may result in inaccurate classification of the residents in the resident assessment classification system;

(b) A risk analysis of an ICFIID with a noticeable change in the frequency distribution of the residents in the resident assessment classification system classifications not attributable to a change in resident population or a significant change in the ICFIID's average case mix score not attributable to a change in resident population or an ICFIID for which other data indicate that the individual assessment form data submitted by the ICFIID may not result in accurate classification of the residents in the resident assessment classification system; or

(c) Prior resident assessment performance of the ICFIID, including, but not limited to, ongoing problems with assessment submission deadlines, error rates, incorrect assessment dates, and apparent unchanged assessment practices following the department's review performed pursuant to section 11 of House Bill 303 of the 129th General Assembly or a subsequent exception review.

(2) The department may contact an ICFIID during the selection process for clarification of information. The ICFIID may be able to satisfactorily resolve the department's concerns and avert an exception review.

(3) At the discretion of the department, an exception review may be conducted on-site at an ICFIID or by desk review except that an exception review shall be conducted on-site at an ICFIID when so requested by the ICFIID.

(D) Requirements for persons conducting exception reviews

(1) Qualified intellectual disability professionals, registered nurses, and other licensed or certified health professionals employed by or under contract with the department shall successfully complete department-approved training in administration of the individual assessment form prior to conducting exception reviews.

(2) Persons conducting exception reviews shall meet the following conditions:

(a) During the period of their employment or contract with the department, reviewers must neither have nor be committed to acquire any direct or indirect financial interest in the ownership, financing, or operation of an ICFIID which they review in Ohio. Employment of a member of a reviewer's family by an ICFIID that the reviewer does not review does not constitute a direct or indirect financial interest in the ownership, financing, or operation of an ICFIID.

(b) Reviewers shall not review any ICFIID that has been a client or employer of the reviewer during the previous twelve months.

(c) Reviewers shall not review any ICFIID where a member of the reviewer's family is a current resident.

(3) When a team of department reviewers conducts an on-site exception review, the team shall be led by a qualified intellectual disability professional.

(E) Prior notice

The department shall notify an ICFIID by telephone at least five calendar days prior to an exception review. At the discretion of the department, the review team may reschedule the exception review if appropriate key personnel of the ICFIID are unavailable on the originally scheduled date of an on-site exception review.

(F) Access to persons and information

An ICFIID selected for exception review shall provide department reviewers with reasonable access to residents, professional and unlicensed direct care staff, staff who assess residents, and residents' completed individual assessment forms, as well as other documentation regarding residents' care needs and treatment. An ICFIID shall also provide the department with sufficient information to be able to contact residents' attending or consulting physicians, other professionals from all disciplines who have observed, evaluated, or treated residents such as contracted therapists, and residents' family/significant others. These sources of information may help to validate information provided on the individual assessment form data submitted to the department. Verification activities may include reviewing residents' individual assessment forms and supporting documentation, conducting interviews with staff knowledgeable about the resident, and observing or interviewing the resident.

(G) Exception review sample

An exception review shall be conducted of a pre-selected random, targeted, or combination sample of completed individual assessment forms from the reporting quarter. If the results of the pre-selected sample indicate inaccuracies which require a larger sample, the department may expand the sample.

(H) Exit conference

At the conclusion of an exception review , department reviewers shall conduct an exit conference with representatives of the ICFIID. At the discretion of the department, the exit conference may be conducted on-site at the ICFIID or by telephone. Reviewers shall share preliminary findings and/or concerns about verification or failure to verify resident assessment classification system classifications for reviewed records. At the time of the exit conference, the ICFIID shall be afforded an opportunity to present additional information or items which depict the needs of residents for whom the ICFIID contests the sample findings.

(I) Written summary of exception review findings

All exception reviews shall include a written summary of exception review findings. The department shall send a copy of the written summary of findings to the ICFIID.

(J) Records retention

All exception review reports shall be retained by the department for at least six years from the date the exception review report is final.

(K) Calculation or recalculation of resident case mix scores

If the exception review tolerance level is exceeded, the department shall use the exception review findings to calculate or recalculate resident case mix scores, quarterly facility average case mix scores, and annual facility average case mix scores. Calculations or recalculations shall apply only to records actually reviewed by the department and shall not be based on extrapolations of findings to unreviewed records. Rates calculated based on exception review findings may result in an increase or decrease compared to the rate based on the ICFIID's assessment of information.

(L) Reconsideration

(1) An ICFIID may submit a written request for reconsideration to the department not later than thirty calendar days after it receives the written summary of exception review findings pursuant to paragraph (I) of this rule. The request shall include:

(a) A detailed explanation of the items in the assessment results that the ICFIID disputes;

(b) Copies of relevant supporting documentation from specific resident records; and

(c) The ICFIID's proposed resolution of the disputes.

(2) Qualified intellectual disability professionals, registered nurses, or other licensed or certified health professionals employed by or under contract with the department, other than those who conducted the exception review, shall consider all of the information submitted by the ICFIID, the historic results of the assessments, and any other information determined necessary for consideration.

(3) The department shall issue a written decision regarding reconsideration within thirty calendar days of receiving the request.

(4) The department's decision is final and not subject to further appeal.

(5) When calculating an ICFIID's case mix scores, the department shall use any resident case mix scores adjusted as a result of a rate consideration determination.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03, 5124.198
Five Year Review Date: 7/8/2023
Prior Effective Dates: 10/1/2013
Rule 5123-7-33 | Intermediate care facilities for individuals with intellectual disabilities - resident assessment classification system based on administration of the Ohio developmental disabilities profile.
 

(A) Purpose

This rule sets forth a method and process for determining the per resident/per day rate paid to an intermediate care facility for individuals with intellectual disabilities (ICFIID) for direct care costs using the Ohio developmental disabilities profile pursuant to sections 5124.19 to 5124.193 of the Revised Code.

(B) Definitions

For the purposes of this rule, the following definitions shall apply:

(1) "Annual facility average case mix score" means the ICFIID's average case mix score of all qualifying quarters in a calendar year.

(2) "Case mix score" means the measure of the relative direct care resources needed to provide care and rehabilitation to a resident of an ICFIID using the Ohio developmental disabilities profile.

(3) "Correction submission due date" means the deadline for an ICFIID to submit corrected Ohio developmental disabilities profile data to the department. The correction submission due date applies to corrections submitted in electronic format for facility level errors and resident record changes.

(4) "Cost per case mix unit" is calculated by dividing an ICFIID's desk-reviewed, actual, allowable, per diem direct care costs for the calendar year preceding the fiscal year in which the rate will be paid by the annual facility average case mix score for the calendar year preceding the fiscal year in which the rate will be paid.

(5) "Facility level errors" means errors which must be corrected before a facility average case mix score can be calculated and include:

(a) Failure to electronically submit the certification of Ohio developmental disabilities profile data by the filing date; and

(b) Incomplete or inaccurate changes to a resident's assessment data are submitted to the department.

(6) "Filing date" means the deadline for initial quarterly electronic submission and certification of an ICFIID's Ohio developmental disabilities profile data, which is the fifteenth calendar day following the reporting period end date.

(7) "Individual assessment form" means the instrument used to assess the needs and circumstances of an individual with developmental disabilities for the purpose of calculating an ICFIID's direct care costs pursuant to sections 5124.195 to 5124.198 of the Revised Code.

(8) "Ohio developmental disabilities profile" means the instrument used to assess the needs and circumstances of an individual with developmental disabilities for the purpose of calculating an ICFIID's direct care component rate pursuant to sections 5124.19 to 5124.193 of the Revised Code.

(9) "Peer group" means one of the following groups of ICFIID:

(a) "Peer group 1-A" includes each ICFIID with a medicaid-certified capacity exceeding sixteen.

(b) "Peer group 2-A" includes each ICFIID with a medicaid-certified capacity exceeding eight but not exceeding sixteen.

(c) "Peer group 3-A" includes each ICFIID with a medicaid-certified capacity of seven or eight.

(d) "Peer group 4-A" includes each ICFIID with a medicaid-certified capacity not exceeding six, other than an ICFIID that is in peer group 5-A.

(e) "Peer group 5-A" includes each ICFIID to which all of the following apply:

(i) The ICFIID is first certified as an ICFIID after July 1, 2014;

(ii) The ICFIID has a medicaid-certified capacity not exceeding six;

(iii) The ICFIID has a contract with the department that is for fifteen years and includes a provision for the department to approve all admissions to, and discharges from, the ICFIID; and

(iv) The ICFIID's residents are admitted to the ICFIID directly from a department-operated ICFIID or have been determined by the department to be at risk of admission to a department-operated ICFIID.

(10) "Processing quarter" means the quarter that follows the reporting quarter and is the quarter in which the department receives the Ohio developmental disabilities profile data for the reporting quarter.

(11) "Quarterly facility average case mix score" means the facility average case mix score based on Ohio developmental disabilities profile data submitted for one reporting quarter.

(12) "Record" means a resident's Ohio developmental disabilities profile data processed by the department.

(13) "Relative resource weight" means the measure of the relative costliness of caring for residents in one case mix classification versus another, indicating the relative amount and cost of staff time required on average for defined job types to care for residents in a single case mix classification.

(14) "Reporting period end date" means the last day of each calendar quarter.

(15) "Reporting quarter" means the quarter which precedes the processing quarter.

(16) "Resident assessment classification system" means the system for classifying residents of an ICFIID into case mix classifications that reflect clusters of residents, defined by resident characteristics, determined using data from the Ohio developmental disabilities profile, that explain resource use.

(17) "Resident case mix score" means the relative resource weight for the classification to which a resident is assigned based on data elements from the resident's Ohio developmental disabilities profile.

(C) Calculating direct care costs

For a period of three years commencing on the effective date of this rule, the department shall calculate for each eligible ICFIID, two separate per resident/per day rates for direct care costs using data from:

(1) Administration of the individual assessment form to residents of the ICFIID in accordance with rule 5123-7-20 of the Administrative Code; and

(2) Administration of the Ohio developmental disabilities profile to residents of the ICFIID in accordance with this rule and rule 5123:2-7-32 of the Administrative Code.

(D) Resident assessment classification system

(1) The department shall use the resident assessment classification system to classify residents of an ICFIID based on the data from the Ohio developmental disabilities profile. Using point values assigned to responses to questions on the Ohio developmental disabilities profile as set forth in the appendix to this rule, the Ohio developmental disabilities profile for each resident will be scored in three distinct domains:

(a) Medical;

(b) Behavioral; and

(c) Adaptive skills.

(2) The department shall calculate a resident's assessment score for each of the medical, behavioral, and adaptive skills domains and assign points:

(a) If the resident's assessment score for the domain is more than one standard deviation above the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, one point;

(b) If the resident's assessment score for the domain is more than one-half standard deviation above the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, and not more than one standard deviation above that mean, two points;

(c) If the resident's assessment score for the domain is more than the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, and not more than one-half standard deviation above that mean, three points;

(d) If the resident's assessment score for the domain is not more than the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, and not more than one-half standard deviation below that mean, four points;

(e) If the resident's assessment score for the domain is more than one-half standard deviation below the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, and not more than one standard deviation below that mean, five points; and

(f) If the resident's assessment score for the domain is more than one standard deviation below the mean assessment score for the domain for all ICFIID residents as of December 31, 2017, six points.

(3) The department shall determine the weighted sum of the points assigned in accordance with paragraph (D)(2) of this rule to each of the resident's domain assessment scores and round the weighted sum to the nearest whole number:

(a) Points assigned to the resident's assessment score for the medical domain shall be weighted at thirty-five per cent;

(b) Points assigned to the resident's assessment score for the behavioral domain shall be weighted at thirty per cent; and

(c) Points assigned to the resident's assessment score for the adaptive skills domain shall be weighted at thirty-five per cent.

(4) The department shall place the resident into an acuity group:

(a) If the resident's weighted sum of points is five or lower, group one;

(b) If the resident's weighted sum of points is at least six and not more than eight, group two;

(c) If the resident's weighted sum of points is nine or ten, group three;

(d) If the resident's weighted sum of points is eleven or twelve, group four;

(e) If the resident's weighted sum of points is at least thirteen and not more than fifteen, group five; and

(f) If the resident's weighted sum of points is sixteen or higher, group six.

(E) Relative resource weights

(1) Analysis of staff time and resident assessment data, collected in a work measurement study of Ohio medicaid-certified ICFIID for the purpose of establishing common staff times associated with all resident classifications that are standard across residents, staff, facilities, and units, determined that the job classifications listed in paragraphs (E)(1)(a) to (E)(1)(h) of this rule are job types that perform activities that vary by case mix classification established using the Ohio developmental disabilities profile. Job types determined not to be positions participating in activities that vary by case mix classification are not used to calculate the relative resource weights described in paragraph (E)(2) of this rule.

(a) Habilitation specialists consisting of nurse aides and habilitation staff;

(b) Licensed practical nurses;

(c) Occupational therapists;

(d) Program specialists;

(e) Qualified intellectual disability professionals;

(f) Registered nurses;

(g) Social workers/counselors; and

(h) Speech therapists.

(2) Each of the six resident acuity groups is assigned a relative resource weight. The relative resource weight indicates the relative amount and cost of staff time required on average for the job types listed in paragraphs (E)(1)(a) to (E)(1)(h) of this rule to deliver care to residents in that classification. The relative resource weight was calculated using the average minutes of care per job type per classification as determined during the work measurement study, and the averages of the wages by job type as reported on the cost report. By setting the wage weight at one for the job type receiving the lowest hourly wage, wage weights for the other job types are calculated by dividing the lowest wage into the wage of each of the other job types. To calculate the total weighted minutes for each classification, the wage weight for each job type is multiplied by the average number of minutes staff of that job type spend caring for a resident in that classification, and the products are summed. The classification with the lowest total weighted minutes receives a relative resource weight of one. Relative resource weights are calculated by dividing the total weighted minutes of the lowest classification into the total weighted minutes of each classification. Weight calculations are rounded to the second decimal place. Relative resource weights for the resident acuity groups are:

(a) Resident acuity group one = 2.75.

(b) Resident acuity group two = 1.86.

(c) Resident acuity group three = 1.43.

(d) Resident acuity group four = 1.31.

(e) Resident acuity group five = 1.12.

(f) Resident acuity group six = 1.00.

(3) Except as provided in paragraph (E)(3)(a) of this rule, relative resource weights may be recalibrated using wage weights based on three-year statewide averages of wages of the job types listed in this rule as reported on the cost report, and minutes of care per job type per resident assessment classification.

(a) The department may recalibrate the relative resource weights no more often than every three years, using the minutes of care per job type per classification from the most current work measurement study and the wages per job type per hour, to be effective at the beginning of the next state fiscal year. When recalibrating the relative resource weights, the department shall use cost report wage data from the most recent three calendar years available ninety calendar days prior to the start of the fiscal year.

(b) The department may recalibrate relative resource weights more frequently if significant variances in wage ratios between job types occur.

(c) The department may rebase the relative resource weights through the deletion or addition of job types or with revised minutes of care per job type by conducting a new work measurement study, if significant changes in the job types or work roles of the job types occur, or following a change in state policy which would significantly affect statewide case mix of the ICFIID population.

(d) After recalibrating or rebasing relative resource weights in accordance with paragraph (E)(3)(a), (E)(3)(b), or (E)(3)(c) of this rule, the department shall use the recalibrated or rebased relative resource weights to recalculate the annual facility average case mix score for the calendar year preceding the fiscal year.

(4) The annual facility average case mix score is used in conjunction with the lesser of the ICFIID's cost per case mix unit or the maximum allowable cost per case mix unit, adjusted by the inflation rate, to establish the direct care rate, as outlined in sections 5124.19 to 5124.193 of the Revised Code. The ICFIID's cost per case mix unit is calculated using the annual facility average case mix score. The method for determining the annual facility average case mix score is described in paragraph (G) of this rule.

(F) Quarterly facility average case mix score

(1) The department shall establish each ICFIID's rate for direct care costs annually pursuant to sections 5124.19 to 5124.193 of the Revised Code. To set the rate, the department shall:

(a) Calculate the ICFIID's cost per case mix unit;

(b) Multiply the lesser of the ICFIID's cost per case mix unit or the maximum cost per case mix unit for the ICFIID's peer group determined pursuant to division (C) of section 5124.19 of the Revised Code by the ICFIID's case mix score for the calendar quarter ending March thirty-first of the calendar year in which the fiscal year for which the rate is set begins, except that for fiscal year 2019, the department shall use the ICFIID's case mix score for the quarter that ends December 31, 2017; and

(c) Multiply the amount determined in accordance with paragraph (F)(1)(b) of this rule by the inflation factor specified in division (D) of section 5124.19 of the Revised Code.

(2) The quarterly facility average case mix score for an ICFIID that submitted Ohio developmental disabilities profile data and modifications timely, and has no facility level errors is calculated by:

(a) Adding together all residents' relative resource weights for the quarter; and

(b) Dividing the sum of relative resource weights by the total number of residents.

(3) The department shall assign a quarterly facility average case mix score or cost per case mix unit used to establish an ICFIID's rate for direct care costs if the ICFIID fails to correct facility level errors. Before taking such action, the department shall permit the ICFIID a reasonable period of time to correct the information, in accordance with rule 5123:2-7-32 of the Administrative Code.

(a) The department may assign a quarterly facility average case mix score that is five per cent less than the ICFIID's quarterly facility average case mix score for the preceding calendar quarter instead of using the quarterly facility average case mix score calculated based on the ICFIID's submitted information as described in paragraph (F)(2) of this rule. If the ICFIID was assigned a quarterly facility average case mix score for the preceding calendar quarter, the assigned quarterly facility average case mix score shall be the score that is five per cent less than that score assigned for the preceding quarter.

(b) The department may assign a cost per case mix unit that is five per cent less than the ICFIID's calculated or assigned cost per case mix unit for the preceding calendar year if the ICFIID has fewer than two acceptable quarterly facility average case mix scores as described in paragraph (G)(1)(b) of this rule.

(G) Annual facility average case mix score

(1) The annual facility average case mix score is used pursuant to section 5124.19 of the Revised Code to compute the cost per case mix unit for the ICFIID and the peer group maximum cost per case mix unit. Ohio developmental disabilities profile data for all four quarters of the calendar year shall be used to calculate the annual facility average case mix score:

(a) The department-assigned facility average case mix scores shall be omitted from the ICFIID's annual average case mix score calculation.

(b) The annual facility average case mix score shall be calculated from no fewer than two acceptable quarterly facility average case mix scores. Acceptable quarterly facility average case mix scores shall be summed and divided by the total number of quarters of acceptable scores. Acceptable quarterly facility average case mix scores for the purposes of calculating the annual facility average case mix score and for paragraph (F)(3) of this rule include quarterly facility average case mix scores calculated based on the ICFIID's submitted information as described in paragraph (F)(2) of this rule.

(2) If at least two acceptable quarterly facility average case mix scores are not available, the department shall assign the cost per case mix unit in accordance with paragraph (F)(3)(b) of this rule.

View AppendixView Appendix

Supplemental Information

Authorized By: 5123.04, 5124.03, 5124.192, 5124.193
Amplifies: 5123.04, 5124.03, 5124.19 to 5124.193
Five Year Review Date: 7/8/2023
Prior Effective Dates: 7/8/2018
Rule 5123-7-34 | Intermediate care facilities for individuals with intellectual disabilities - quality indicators and the quality incentive payment program.
 

(A) Purpose

This rule sets forth a method and process for determining the quality incentive payment that may be paid to an intermediate care facility for individuals with intellectual disabilities (ICFIID) for achieving quality indicators pursuant to section 5124.24 of the Revised Code.

(B) Definitions

For the purposes of this rule, the following definitions apply:

(1) "Change of operator" has the same meaning as in section 5124.01 of the Revised Code.

(2) "Cost report" has the same meaning as in rule 5123-7-12 of the Administrative Code.

(3) "Direct care staff" means activity staff, habilitation staff, habilitation supervisors, nurse aides, nurses, and qualified intellectual disability professionals.

(4) "Individual plan" has the same meaning as in rule 5123:2-3-03 of the Administrative Code.

(5) "Inpatient days" has the same meaning as in section 5124.01 of the Revised Code.

(6) "Quality incentive payment" means a rate enhancement, available beginning with fiscal year 2022, that is a component of an ICFIID's per diem rate, available to an eligible ICFIID that chooses to achieve quality indicators and meets the requirements set forth in this rule.

(7) "Quality indicator" means one of the five standards set forth in paragraph (D) of this rule.

(C) Participation and eligibility for the quality incentive payment

(1) Participation in the quality incentive payment program is voluntary. An ICFIID that chooses to participate may elect to do so for one or more quality indicators.

(2) To be eligible for participation in the quality incentive payment program, an ICFIID is to have been in operation for at least three months prior to the last day of the calendar year for which it is submitting a cost report.

(3) In the case of a change of operator, an entering operator may be eligible for the quality incentive payment determined only for a cost report period commencing after the effective date of the change of operator.

(4) An ICFIID whose license has been suspended, proposed for revocation, or revoked at any time during a cost report period is ineligible for a quality incentive payment for the following fiscal year.

(D) Quality indicators

Five quality indicators have been established for purposes of the quality incentive payment program:

(1) The ICFIID has developed and implemented a written policy to annually conduct satisfaction surveys for residents of the ICFIID. The policy is to set forth that:

(a) The survey will address, at a minimum:

(i) The degree to which a resident feels happy and safe living in the ICFIID;

(ii) Staff interactions;

(iii) The level to which a resident and/or his or her guardian are involved in person-centered planning;

(iv) Community activities; and

(v) Medical care.

(b) The ICFIID will ensure and document that the satisfaction survey is completed by or offered to each resident and/or the resident's guardian, family member, or advocate.

(c) The ICFIID will summarize the survey results and share the summarized survey results with residents, guardians, family members, and advocates.

(d) The ICFIID will develop a plan to respond to any concerns identified through administration of the survey.

(2) The ICFIID has developed and implemented a written policy to ensure individual plans are person-centered. At a minimum, the policy will:

(a) Set forth a process for obtaining input from residents, guardians, and direct care staff.

(b) Address the seven essential elements of person-centered planning:

(i) Language in the individual plan is descriptive, respectful, empowering, and uses everyday words that the resident, persons important to the resident, and direct care staff understand;

(ii) The individual plan identifies positive information and builds on the resident's strengths, using a trauma-informed approach;

(iii) Important ideas are organized and interwoven through the individual plan so that it is clear that outcomes and services flow from information outlined elsewhere in the individual plan;

(iv) What is important for the resident and what is important to the resident is specific, detailed, and reflected in outcomes and services;

(v) Outcomes are clear and action steps describe how progress will be measured;

(vi) The individual plan includes a clear description of services and supports necessary to address the resident's needs and preferred method for delivery; and

(vii) The individual plan includes the type, scope, amount, frequency, duration, and provider type of services to be delivered.

(3) The ICFIID has developed and implemented a written policy to ensure that each resident has opportunities to experience community integration on a person-centered basis.

(4) The ICFIID has developed and implemented a written policy to ensure all direct care staff successfully complete, on an annual basis, at least one hour of training specific to resident or staff needs that is above and beyond the training described in paragraph (F)(1)(j) of rule 5123:2-3-01 of the Administrative Code. The training may vary among staff.

(5) The ICFIID has developed and implemented a written policy for staff retention that includes measuring staff turnover.

(E) Awarding points for quality indicators

(1) Each quality indicator is associated with one point, for a maximum possible five points.

(2) An ICFIID will indicate its intent to receive the point for a quality indicator by attesting on its cost report that it has achieved the quality indicator and attaching its written policy for the quality indicator. To continue to receive the point for a quality indicator, the ICFIID will attach its written policy for the quality indicator to subsequent cost reports and indicate if the written policy has been amended since the prior submission.

(3) An eligible ICFIID will receive the point for a quality indicator when:

(a) The ICFIID attests it has achieved the quality indicator;

(b) The ICFIID attaches its written policy for the quality indicator with its cost report; and

(c) Absent a determination by the department that:

(i) The written policy for the quality indicator fails to meet the requirements set forth in this rule; or

(ii) The ICFIID fails to implement the written policy.

(F) Calculation of the quality incentive payment

An ICFIID's per diem quality incentive payment for a fiscal year will be calculated in accordance with section 5124.24 of the Revised Code.

(G) Verifying achievement of quality indicators

(1) The department will use two methods to verify a participating ICFIID's achievement of quality indicators.

(a) Review of written policy

(i) Department staff will review each written policy for a quality indicator submitted by an ICFIID to ensure the policy meets the requirements set forth in this rule. The written policies will be reviewed as part of the desk review of the ICFIID's cost report conducted in accordance with rule 5123-7-12 of the Administrative Code.

(ii) The department will notify an ICFIID by electronic mail within fifteen calendar days of completing the desk review when the department finds that the written policy fails to meet the requirements set forth in this rule. The notice will inform the ICFIID that it is ineligible to receive the quality incentive payment for that quality indicator for the following fiscal year and should adjust its cost report accordingly.

(iii) An ICFIID may electronically submit a request for reconsideration of the department's finding that includes written justification within fifteen calendar days of receipt of the desk review finding.

(iv) The department will respond by electronic mail to the request for reconsideration within fifteen calendar days of receipt.

(b) Review of implementation of written policy

(i) Department staff will review the ICFIID's implementation of the written policy for a quality indicator during an on-site visit to the ICFIID. The department will notify an ICFIID by electronic mail at least fifteen calendar days in advance of the on-site visit. When an ICFIID indicates it has achieved more than one quality indicator, department staff will review implementation of at least two quality indicators.

(a) For purposes of reviewing implementation of the written policy for a quality indicator described in paragraph (D)(1), (D)(2), or (D)(3) of this rule, the department will select a random sample of residents for review. The number of residents selected will be two or twenty per cent, whichever is larger.

(b) For purposes of reviewing implementation of the written policy for the quality indicator described in paragraph (D)(4) of this rule, the department will select a random sample of direct care staff for review. The number of direct care staff selected will be two or twenty per cent, whichever is larger.

(c) For purposes of reviewing implementation of the written policy for the quality indicator described in paragraph (D)(5) of this rule, the department will examine the ICFIID's measurements or reports of staff turnover for the cost report period.

(ii) The department will notify an ICFIID by electronic mail within fifteen calendar days of completing the on-site review when the department finds that the ICFIID failed to implement the written policy. The notice will inform the ICFIID that it is ineligible to receive the quality incentive payment for that quality indicator for the following fiscal year and should adjust its cost report accordingly.

(iii) An ICFIID may electronically submit a request for reconsideration of the department's finding that includes written justification with supporting documentation within fifteen calendar days of receipt of the on-site review finding.

(iv) The department will respond by electronic mail to the request for reconsideration within fifteen calendar days of receipt.

(2) If the department determines that an ICFIID improperly attested achievement of a quality indicator on its cost report, the department will reject the cost report and the ICFIID will submit a corrected cost report in accordance with rule 5123-7-12 of the Administrative Code. The ICFIID will not receive a quality incentive payment for the quality indicator.

Supplemental Information

Authorized By: 5123.04, 5124.03, 5124.24
Amplifies: 5123.04, 5124.03, 5124.24
Five Year Review Date: 12/17/2025