Skip to main content
Back To Top Top Back To Top
This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 5123:2-7 | Intermediate Care Facilities

 
 
 
Rule
Rule 5123:2-7-08 | Intermediate care facilities for individuals with intellectual disabilities - bed-hold days.
 

(A) Purpose

This rule establishes requirements and procedures for an intermediate care facility for individuals with intellectual disabilities (ICFIID) to be reimbursed for reserving a bed for a resident who is temporarily absent.

(B) Definitions

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

(1) "Admission" occurs when an individual who was not being counted in the census of any Ohio medicaid-certified ICFIID becomes a resident of an ICFIID. An admission may be a new admission or a return admission after a discharge.

(2) "Bed-hold day" means a day for which a bed is reserved for a resident of an ICFIID through medicaid reimbursement while the resident is temporarily absent from the ICFIID for hospitalization, therapeutic leave, or a visit with friends or relatives. Reimbursement for bed-hold days may be made only if the resident has the intent and ability or may have cause to return to the same ICFIID. A resident on bed-hold day status is not considered discharged because the ICFIID is reimbursed to hold the bed while the resident is on temporary leave.

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

(5) "Discharge" means the full release of a resident from an ICFIID so that he or she is no longer counted in the ICFIID's census. Reasons for discharge include, but are not limited to, the resident's move to another ICFIID, decision to reside in a community-based setting, or death. The day of discharge is not counted as a bed-hold day or an occupied day except when discharge and admission occur on the same day, in which case the day is considered a day of admission and counts as one occupied day.

(6) "Home and community-based services" has the same meaning as in section 5123.01 of the Revised Code.

(7) "Hospital" has the same meaning as in rule 3701-59-01 of the Administrative Code.

(8) "Hospitalization" means a resident is temporarily absent from an ICFIID for the purpose of receiving services or being treated in a hospital.

(9) "Institution for mental disease" has the same meaning as in rule 5160-3-16.4 of the Administrative Code.

(10) "Occupied day" means either:

(a) A day of admission; or

(b) A day during which a medicaid-eligible resident's stay in an ICFIID is eight or more hours. A day begins at twelve a.m. and ends at eleven fifty-nine p.m.

(11) "Readmission" occurs when a resident returns to the same ICFIID following use of bed-hold days.

(12) "Skilled nursing facility" means a nursing facility certified to participate in the medicare program.

(13) "Therapeutic leave" means a resident is temporarily absent from an ICFIID, and is in a residential setting other than a long-term care facility, hospital, or other entity eligible to receive federal, state, or county funds to maintain a resident, for the purpose of receiving a regimen of therapeutic services or visiting a potential new residential setting.

(C) Prohibition of preadmission bed-hold payment

(1) The department shall not make payment to an ICFIID to reserve a bed for a medicaid-eligible prospective resident.

(2) An ICFIID shall not accept preadmission payment to reserve a bed from a medicaid-eligible prospective resident or from any other source on the prospective resident's behalf as a precondition for admission.

(D) Limits and reimbursement for bed-hold days

(1) For a medicaid-eligible resident of an ICFIID, except those excluded in accordance with paragraph (H) of this rule, the department may reimburse the ICFIID to reserve a bed only for as long as the resident has a developmental disabilities level of care determination and intends or may have cause to return to the same ICFIID, but not for more than thirty days in any calendar year unless additional days have been authorized by the department in accordance with paragraph (E) of this rule.

(2) Reimbursement for bed-hold days shall be paid at one hundred per cent of the ICFIID's per diem rate.

(3) Reimbursement for bed-hold days may be made for the following reasons:

(a) Hospitalization

Bed-hold days used for hospitalization may be reimbursed only until:

(i) The day the resident's anticipated level of care at time of discharge from the hospital changes to a level of care that the ICFIID is not certified to provide;

(ii) The day the resident is discharged from the hospital, including discharge resulting in transfer to the ICFIID, a nursing facility, or a skilled nursing facility;

(iii) The day the resident decides to go to another ICFIID upon discharge from the hospital and notifies the first ICFIID; or

(iv) The day the hospitalized resident dies.

(b) Therapeutic leave

(i) A plan to use bed-hold days for therapeutic leave for the purpose of receiving a regimen of therapeutic services must be approved in advance by the resident's primary physician and documented in the resident's medical record. The documentation shall be available for viewing by the department.

(ii) A plan to use bed-hold days for therapeutic leave for the purpose of visiting a potential new residential setting must be approved in advance by the resident's primary physician or a qualified intellectual disability professional and documented in the resident's medical record or individual plan. The documentation shall be available for viewing by the department.

(iii) An ICFIID shall make arrangements for the resident to receive required care and services while on approved therapeutic leave. Medicaid funding, however, shall not be used for state plan home health services, durable medical equipment, and/or private duty nursing on days for which the ICFIID receives reimbursement for bed-hold days.

(c) Visit with friends or relatives

(i) A plan to use bed-hold days to visit with friends or relatives must be approved in advance by the resident's primary physician or a qualified intellectual disability professional and documented in the resident's medical record or individual plan. The documentation shall be available for viewing by the department.

(ii) An ICFIID shall make arrangements for the resident to receive required care and services while on approved visits. Medicaid funding, however, shall not be used for state plan home health services, durable medical equipment, and/or private duty nursing on days for which the ICFIID receives reimbursement for bed-hold days.

(iii) The number of days per visit is flexible within the maximum bed-hold days, allowing for differences in the resident's physical condition, the type of visit, and travel time.

(4) The number and frequency of bed-hold days used shall be considered in evaluating the continuing need of a resident for care in an ICFIID.

(E) Requests for additional bed-hold days

(1) Additional bed-hold days beyond the original thirty days in a calendar year require prior authorization except in the event of emergency hospitalization. In the event of emergency hospitalization, authorization may be requested after the fact if the request is submitted within one business day of the first day of hospitalization. A maximum of thirty additional consecutive bed-hold days may be authorized per request.

(2) An ICFIID shall submit a request for additional bed-hold days to the department electronically via the department's website. The request shall be consistent with the goals of the resident's individual plan and medical records, and shall include:

(a) Reason for bed-hold days (i.e., hospitalization, therapeutic leave, or visit with friends or relatives);

(b) Projected dates of absence; and

(c) Projected date of return.

(3) The department shall review the request for additional bed-hold days and send notice within five business days of approval or denial to the ICFIID.

(a) When a request is approved, the notice shall specify the time period during which the bed-hold days may be used.

(b) When a request is denied, the notice shall specify the reason for denial and explain the individual's right to a state hearing in accordance with section 5101.35 of the Revised Code.

(4) The department shall review prior authorization requests on a case-by-case basis. Conditions under which prior authorization may be denied include, but are not limited to, visits with friends or relatives exceeding thirty consecutive days or forty-five total days in a calendar year.

(5) An approved request for additional bed-hold days is for the specified period of time only. Unused bed-hold days from an approved request shall not be used at a later time. A new prior authorization request must be submitted if additional bed-hold days are required during that same calendar year.

(6) Bed-hold days beyond the original thirty days used without prior authorization may result in an adjustment to the ICFIID's reimbursement.

(F) Readmission

An ICFIID shall readmit a resident upon depletion of approved bed-hold days or at any time prior to depletion of approved bed-hold days upon the resident's request for readmission.

(G) Residents eligible for bed-hold days

(1) Medicaid reimbursement for bed-hold days is available under the provisions specified in this rule if a resident:

(a) Is eligible for medicaid services and has met the patient liability and financial eligibility requirements set forth in rule 5160:1-3-04.3 of the Administrative Code;

(b) Requires a developmental disabilities level of care; and

(c) Is not excluded in accordance with paragraph (H) of this rule.

(2) If a resident meets all of the criteria in paragraph (G)(1) of this rule and is pending approval of a medicaid application and requires bed-hold days, medicaid reimbursement shall be made retroactive to the date the resident became medicaid-eligible and approved for medicaid vendor reimbursement through the date the resident returns from a leave or until the maximum number of bed-hold days are exhausted.

(H) Exclusions

Bed-hold days are not available to a medicaid-eligible resident of an ICFIID who is:

(1) Enrolled in a medicare or medicaid hospice program;

(2) Over age twenty-one and under age sixty-five and becomes a patient of an institution for mental disease;

(3) Enrolled in a home and community-based services waiver;

(4) In a period of restricted medicaid coverage because of an improper transfer of resources as set forth in rule 5160:1-3-07.2 of the Administrative Code; or

(5) Relocating due to anticipated closure of an ICFIID, an ICFIID's voluntary withdrawal from participation in the medicaid program, or other events that result in termination of an ICFIID's medicaid provider agreement except when the ICFIID becomes a downsized ICFIID as defined in section 5124.01 of the Revised Code or converts beds from ICFIID services to home and community-based services in accordance with section 5124.60 or 5124.61 of the Revised Code. No span of bed-hold days shall be approved that ends on an ICFIID's date of closure or termination from participation in the medicaid program.

(I) Compliance

(1) Without limiting such other remedies provided by law for noncompliance with this rule:

(a) The Ohio department of medicaid may terminate the ICFIID's provider agreement; or

(b) The department may require the ICFIID to submit and implement a corrective action plan on a schedule specified by the department.

(2) An ICFIID shall cooperate with any investigation and shall provide copies of any records requested by the department or the Ohio department of medicaid.

Last updated July 30, 2021 at 2:21 PM

Supplemental Information

Authorized By: 5123.04, 5124.02, 5124.03, 5124.34, 5164.02
Amplifies: 5123.04, 5124.02, 5124.03, 5124.34, 5164.02
Five Year Review Date: 12/28/2021
Rule 5123:2-7-11 | Intermediate care facilities for individuals with intellectual disabilities - relationship of other covered medicaid services.
 

(A) Purpose

This rule identifies covered services generally available to individuals who are eligible for medicaid and describes the relationship of such services to those provided to residents of an intermediate care facility for individuals with intellectual disabilities (ICFIID) other than a state-operated ICFIID. Reimbursement of services through the "ICFIID cost report mechanism" referenced in this rule is governed by rule 5123:2-7-12 of the Administrative Code.

(B) Dental services

All covered dental services provided by licensed dentists are reimbursed directly to the provider of the dental services in accordance with Chapter 5160-5 of the Administrative Code. Personal hygiene services provided by staff or contracted personnel of the ICFIID are reimbursed through the ICFIID cost report mechanism.

(C) Laboratory and x-ray services

Costs incurred for the purchase and administration of tuberculin tests, and for drawing specimens and forwarding specimens to a laboratory, are reimbursed through the ICFIID cost report mechanism. All laboratory and x-ray procedures covered under the medicaid program are reimbursed directly to the laboratory or x-ray provider in accordance with Chapter 5160-11 of the Administrative Code.

(D) Medical supplier services

(1) Medical supplier services that are reimbursed through the ICFIID cost report mechanism include:

(a) Costs incurred for "needed medical and program supplies," defined as items that have a very limited life expectancy. Such items include atomizers, nebulizers, bed pans, catheters, electric pads, hypodermic needles, syringes, incontinence pads, splints, and disposable ventilator circuits.

(b) Costs incurred for the purchase and repair of "needed medical equipment," defined as items that can stand repeated use, are primarily and customarily used to serve a medical purpose, are not useful to a person in the absence of illness or injury, and are appropriate for use in the ICFIID. Such items include hospital beds, wheelchairs, and intermittent positive-pressure breathing machines, except as noted in paragraph (D)(2) of this rule.

(c) Costs of equipment associated with oxygen administration such as carts, regulators, humidifiers, cannulas, masks, and demurrage.

(2) Medical supplier services that are reimbursed directly to the medical supplier provider in accordance with Chapter 5160-10 of the Administrative Code include:

(a) Certain durable medical equipment items, specifically, ventilators and custom-made wheelchairs that have parts which are actually molded to fit the resident.

(b) "Prostheses," defined as devices that replace all or part of a body organ to prevent or correct physical deformity or malfunction. Such devices include artificial arms or legs, electro-larynxes, and breast prostheses.

(c) "Orthoses," defined as devices that assist in correcting or strengthening a distorted part. Such devices include arm braces, hearing aids and batteries, abdominal binders, and corsets.

(d) Contents of oxygen cylinders or tanks including liquid oxygen, except emergency stand-by oxygen which is reimbursed through the ICFIID cost report mechanism.

(e) Oxygen-producing machines (concentrators) for specific use by an individual resident.

(E) Pharmaceuticals

(1) Over-the-counter drugs covered in accordance with rule 5160-9-03 of the Administrative Code and nutritional supplements are reimbursed through the ICFIID cost report mechanism.

(2) Pharmaceuticals reimbursed directly to the pharmacy provider are subject to the limitations in Chapter 5160-9 of the Administrative Code, the limitations established by the Ohio state board of pharmacy, and the following conditions:

(a) When new prescriptions are necessary following expiration of the last refill, the new prescription may be ordered only after the physician examines the resident.

(b) A copy of all records regarding prescribed drugs for a resident of an ICFIID shall be retained by the dispensing pharmacy for at least six years. A receipt for drugs delivered to an ICFIID shall be signed by a representative of the ICFIID at the time of delivery and a copy retained by the pharmacy.

(F) Therapy services

(1) Costs incurred for physical therapy, occupational therapy, speech therapy, and audiology services provided by licensed therapists or therapy assistants that are covered for residents of an ICFIID by medicaid are reimbursed through the ICFIID cost report mechanism.

(2) Costs incurred for psychology services provided by licensed psychologists or psychology assistants that are covered for residents of an ICFIID by medicaid are reimbursed through the ICFIID cost report mechanism. No reimbursement for psychology services shall be made to a provider other than the ICFIID or a community mental health center certified by the Ohio department of mental health and addiction services. Services provided by an employee of the community mental health center shall be billed directly to medicaid by the community mental health center.

(3) Costs incurred for respiratory therapy services provided by licensed respiratory care professionals that are covered for residents of an ICFIID by medicaid are reimbursed through the ICFIID cost report mechanism. No reimbursement for respiratory therapy services shall be made to a provider other than the ICFIID.

(4) Reasonable costs for rehabilitative, restorative, or maintenance therapy services rendered to residents of an ICFIID by staff or contracted personnel of the ICFIID and the overhead costs to support the provision of such services are reimbursed through the ICFIID cost report mechanism.

(G) Physician services

(1) A physician may be directly reimbursed for providing the following services to a resident of an ICFIID:

(a) All covered diagnostic and treatment services in accordance with Chapter 5160-4 of the Administrative Code.

(b) All medically necessary physician visits in accordance with rule 5160-4-06 of the Administrative Code.

(c) All required physician visits as described in this rule when the services are billed in accordance with rule 5160-4-06 of the Administrative Code.

(i) Physician visits provided to a resident of an ICFIID are considered timely if they occur no later than ten calendar days after the date the visit was requested.

(ii) For reimbursement of the required physician visits, the physician shall:

(a) Review the resident's total program of care including medications and treatments at each visit required by this rule;

(b) Write, sign, and date progress notes at each visit;

(c) Sign all orders; and

(d) Personally visit the resident except as provided in paragraph (G)(1)(c)(iii) of this rule.

(iii) At the option of the physician, required visits after the initial visit may be delegated in accordance with paragraph (G)(1)(c)(iv) of this rule and alternate between physician and visits by a physician assistant or certified nurse practitioner.

(iv) A physician may delegate tasks to a physician assistant (in accordance with Chapter 4730. of the Revised Code and Chapter 4730-1 of the Administrative Code) or a certified nurse practitioner (in accordance with Chapter 4723. of the Revised Code and Chapter 4723-4 of the Administrative Code) provided the physician assistant or certified nurse practitioner is acting within the scope of his or her practice and is under supervision and employment of the billing physician. A physician may not delegate a task when regulations specify that the physician must perform it personally or when delegation is prohibited by state law or the ICFIID's policies.

(2) Services directly reimbursed to the physician shall be:

(a) Based on medical necessity, as defined in rule 5160-1-01 of the Administrative Code, and requested by the resident of the ICFIID with the exception of the required visits described in paragraph (G)(1)(c) of this rule.

(b) Documented by entries in the resident's medical record along with any symptoms and findings. Each entry shall be signed and dated by the physician.

(3) Services provided in the capacity of overall medical direction are reimbursed only to an ICFIID and may not be directly reimbursed to a physician.

(H) Podiatry services

Covered services provided by licensed podiatrists are reimbursed directly to the authorized podiatric provider in accordance with Chapter 5160-7 of the Administrative Code.

(I) Transportation services

Costs incurred by the ICFIID for transporting residents by means other than covered ambulance or ambulette services are reimbursed through the ICFIID cost report mechanism. Payment is made directly to authorized providers for covered ambulance and ambulette services as set forth in Chapter 5160-15 of the Administrative Code.

(J) Vision care services

All covered vision care services, including examinations, dispensing, and the fitting of eyeglasses, are reimbursed directly to authorized vision care providers in accordance with Chapter 5160-6 of the Administrative Code.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03
Five Year Review Date: 7/1/2022
Rule 5123:2-7-15 | Intermediate care facilities for individuals with intellectual disabilities - claim submission, payment, and adjustment process.
 

(A) Purpose

This rule establishes procedures for an intermediate care facility for individuals with intellectual disabilities (ICFIID) to submit claims and be paid for services rendered.

(B) Exchanging information regarding residents of an ICFIID

(1) Notification of change in income

An ICFIID shall notify the department in a format prescribed by the department and notify the county department of job and family services via email of a change in the income of a medicaid-eligible resident within five calendar days following the ICFIID's awareness of the change in income.

(2) Notification of death

An ICFIID shall notify the department in a format prescribed by the department and notify the county department of job and family services via email of the death of a medicaid-eligible resident within five calendar days following the resident's death. Within ten calendar days of receipt of the notification, the county department of job and family services shall terminate medicaid eligibility.

(C) Submission of claims for services included in the ICFIID per diem rate

(1) An ICFIID shall submit claims for payment for services that are included in the ICFIID per diem rate either directly or as a trading partner as defined in rule 5160-1-20 of the Administrative Code or through another trading partner. The ICFIID shall be a medicaid provider in an active enrollment status for all dates within the claim span.

(2) The ICFIID shall electronically submit claims for payment, including adjustments, for services that are included in the ICFIID per diem rate in one of the following formats:

(a) Electronic data interchange, in accordance with standards established under 45 C.F.R. 160, 45 C.F.R. 162, and 45 C.F.R. 164 as in effect on the effective date of this rule, using the 837 health care claim institutional (837I) electronic format (2015), which is available at the national uniform billing committee website (http://nubc.org/ subscriber/index.dhtml); or

(b) The medicaid information technology system web portal.

(3) Claim submissions shall comply with the UB-04 national uniform billing data specifications and be submitted in accordance with the correct national coding initiative and coding standards as set forth in the following guides and as described in 45 C.F.R. 162.1000 and 45 C.F.R. 162.1002 as in effect on the effective date of this rule:

(a) Healthcare common procedure coding system;

(b) Current procedure terminology codebook; and

(c) International classification of diseases codebook.

(4) Trading partners who submit electronic data interchange claim transactions shall follow the requirements set forth in paragraph (H) of rule 5160-1-19 of the Administrative Code.

(5) Claim submissions shall comply with the current version of the claim transaction requirements in this rule and as specified in the Ohio department of medicaid 837I companion guide (May 12, 2014), which is available at the Ohio department of medicaid website (http://medicaid.ohio.gov/providers/ mits/hipaa5010implementation. aspx).

(6) A single claim shall include days of service provided, including qualifying leave days, for a single resident within a single calendar month and shall not cross calendar months. If an ICFIID determines that a claim that has been paid should have included additional per diem service days, the ICFIID shall timely submit an adjustment claim correcting the entire calendar month's claim information.

(7) When a medicaid-eligible resident of an ICFIID has a patient liability obligation, the entire monthly amount of patient liability, as determined in accordance with rule 5160:1-3-04.3 of the Administrative Code, shall be reported by the ICFIID on the resident's monthly claim. When a resident is admitted, discharged, transfers to another facility, or switches from medicare to medicaid mid-month, the entire monthly amount of patient liability shall be reported on the claim for that month. The patient liability shall be applied as an offset against the amount medicaid would otherwise reimburse for the claim. When the patient liability exceeds the amount medicaid would reimburse, the claim shall be processed with a payment of zero dollars.

(8) The treatment of lump sum payments and their disposition regarding medicaid eligibility are addressed in rule 5160:1-3-05.8 of the Administrative Code; if however, the county department of job and family services and the medicaid-eligible resident determine that the lump sum shall be assigned to the ICFIID as payment for past per diem services received by the resident, the ICFIID shall submit adjustment claims for as many prior months as necessary to fully offset the amount of the lump sum payment that was assigned to the ICFIID. When there are lump sum monies remaining after adjusting all prior payments, the ICFIID shall apply the remaining lump sum balance to current and future claims. When the resident is discharged or passes away prior to exhausting the lump sum payment, the ICFIID shall return the balance to the individual or the individual's estate.

(9) Timely filing requirements

(a) Original claim submission

(i) A claim must be received by the Ohio department of medicaid within three hundred sixty-five calendar days of the actual date of service.

(ii) A claim received beyond three hundred sixty-five calendar days of the actual date of service shall be denied except when the provisions of paragraph (C)(10) of this rule apply.

(iii) For purposes of this rule, the date of receipt shall be determined by the date the claim is received in the medicaid information technology system web portal or the date the claim is received via electronic data interchange.

(b) Resubmission of a denied claim

(i) A claim denied by the Ohio department of medicaid may be resubmitted for payment but the resubmission must be received by the Ohio department of medicaid no later than the later of the following dates:

(a) Three hundred sixty-five calendar days from the actual date of service; or

(b) One hundred eighty calendar days from the date the claim was denied, even if this date is beyond three hundred sixty-five calendar days from the actual date of service.

(ii) A resubmitted claim received beyond seven hundred thirty calendar days from the actual date of service shall be denied.

(c) Adjustment to a previously paid claim, including a claim paid at zero dollars

(i) When an ICFIID identifies an underpaid claim, the ICFIID shall submit an adjustment to the Ohio department of medicaid within one hundred eighty calendar days of the date the underpaid claim was paid by the Ohio department of medicaid.

(ii) When an ICFIID identifies an overpaid claim, the ICFIID shall submit an adjustment to the Ohio department of medicaid within sixty calendar days of identifying the overpayment. The Ohio department of medicaid shall not accept a check from the ICFIID in lieu of a claim adjustment in this situation.

(iii) When the Ohio department of medicaid identifies the need for an ICFIID to adjust a claim, it shall notify the ICFIID to make the adjustment. The ICFIID shall make the adjustment within sixty calendar days of notification. If the ICFIID fails to make the adjustment, the Ohio department of medicaid shall either make the adjustment or void the claim as is appropriate for the fact pattern.

(iv) If within sixty calendar days of the date the Ohio department of medicaid processes an adjustment, there are no outgoing payments for the ICFIID against which the adjustment can be made, the Ohio department of medicaid shall issue an invoice to the ICFIID for the resulting credit balance. The ICFIID shall seek reconsideration or remit payment to the Ohio department of medicaid within sixty calendar days of the date of the invoice. The ICFIID shall include a copy of the invoice with the payment. If the ICFIID fails to include a copy of the invoice or remit full payment, the unpaid balance shall be certified to the Ohio attorney general for collection.

(d) A claim with prior payment by medicare or another insurance plan shall be submitted by the ICFIID within one hundred eighty calendar days from the date medicare or other insurance plan paid the claim to the ICFIID.

(10) Exceptions to filing timelines

(a) When submission of a claim is delayed due to the pendency of either an administrative hearing decision by the Ohio department of job and family services or an eligibility determination by a county department of job and family services, the claim must be received within one hundred eighty calendar days of the date of the administrative hearing decision or eligibility determination. The ICFIID shall maintain all documentation supporting the information on the claim and shall produce the documentation upon request. In no case shall a delay in processing eligibility information under rule 5160:1-2-11 of the Administrative Code be a basis for denial of payment under this provision.

(b) When a claim cannot be submitted to the Ohio department of medicaid within three hundred sixty-five calendar days of the actual date of service due to coordination of benefits delays with medicare and/or other insurance plans, the claim must be received by the Ohio department of medicaid within one hundred eighty calendar days from the date medicare or other insurance plan paid the claim.

(D) Submission of claims for services not included in the ICFIID per diem rate

An ICFIID shall submit medicare crossover claims and claims for medicaid reimbursement for allowable services that are not included in the ICFIID per diem rate in accordance with the requirements set forth in rule 5160-1-19 of the Administrative Code.

Supplemental Information

Authorized By: 5123.04, 5124.03
Amplifies: 5123.04, 5124.03
Five Year Review Date: 7/1/2022
Prior Effective Dates: 7/1/2015
Rule 5123:2-7-29 | Intermediate care facilities for individuals with intellectual disabilities - ventilator services.
 

(A) Purpose

This rule sets forth requirements for an intermediate care facility for individuals with intellectual disabilities (ICFIID) to provide and be reimbursed for providing services to residents who are dependent on invasive mechanical ventilators.

(B) Definitions

(1) "Adult" means a person twenty-two years of age or older.

(2) "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.

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

(4) "Designated outlier coordinator" means a department staff member who coordinates the general operations of the ICFIID outlier services program. The designated outlier coordinator works with providers of outlier services, individuals requesting and receiving outlier services, other persons whom individuals have identified, other service agencies, and other department staff. The designated outlier coordinator's duties include, but are not limited to:

(a) Assisting with the initial approval and ongoing monitoring of an ICFIID providing outlier services;

(b) Coordinating the processing of pre-admission and continued stay prior authorization requests for individuals; and

(c) Reviewing assessments, individual plans, day programming plans, staffing plans, and other documents.

(5) "Individual plan" means a written description of the services to be provided to an individual, developed by an interdisciplinary team that represents the professions, disciplines, or service areas that are relevant to identifying the individual's needs, as described by the comprehensive functional assessments.

(6) "Invasive mechanical ventilator" means a ventilator that is interfaced directly with the individual via an artificial airway (e.g., tracheostomy tube). Invasive mechanical ventilators (volume and/or pressure) are life support devices designed specifically for invasive mechanical ventilation applications and must accommodate direct current backup power supply and include disconnect, high pressure, low pressure, and power loss alarms.

(7) "Nurse" means a person authorized by Chapter 4723. of the Revised Code to engage in the practice of nursing as a registered nurse or a licensed practical nurse.

(8) "Outlier services" means those clusters of services that have been determined by the department to require reimbursement rates established pursuant to section 5124.152 of the Revised Code when delivered by qualified providers to individuals who have been prior-authorized to receive a category of service identified as an outlier service by the department as set forth in Chapter 5123:2-7 of the Administrative Code.

(9) "Pediatric ventilator services" means services provided by an ICFIID in accordance with rule 5123:2-7-29 of the Administrative Code as it existed on the day immediately prior to the effective date of this rule.

(10) "Physician" means a person authorized by Chapter 4731. of the Revised Code to practice medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery.

(11) "Plan of correction" means a corrective action plan prepared by an ICFIID in response to deficiencies cited by the department or the Ohio department of health. The plan shall conform to regulations and guidelines and include information that describes how the deficiency will be corrected, when it will be corrected, how other residents that may be affected by the deficiency will be identified, and how the ICFIID will ensure that compliance is maintained upon correction.

(12) "Prior authorization assessment for ventilator services" means an evaluation to determine if an individual meets the eligibility criteria to receive ventilator services set forth in paragraphs (C)(3) to (C)(6) of this rule that shall take place only after the individual is determined to meet the financial eligibility and level of care requirements set forth in paragraphs (C)(1) and (C)(2) of this rule.

(13) "Prior authorization for ventilator services" means department approval obtained by an ICFIID to provide ventilator services to a specific individual for specific time-limited initial or continued stay periods. Prior authorization for ventilator services shall be required for the ICFIID to be authorized by the department to provide ventilator services and to receive reimbursement for services rendered to the individual. Reimbursement may be denied for any service not rendered in accordance with Chapters 5160-3 and 5123:2-7 of the Administrative Code.

(14) "Registered nurse" has the same meaning as in section 4723.01 of the Revised Code.

(15) "Respiratory care professional" means a person who is licensed under Chapter 4761. of the Revised Code to practice the full range of respiratory care services described in division (A) of section 4761.01 of the Revised Code.

(16) "Ventilator services" means services provided by an ICFIID that holds an effective provider agreement with the Ohio department of medicaid and that is approved by the department to deliver outlier services to individuals who are dependent on invasive mechanical ventilators.

(C) Individual eligibility criteria

To receive prior authorization for ventilator services, an individual shall:

(1) Have been determined by the county department of job and family services to meet the medicaid financial eligibility standards for institutional care.

(2) Have obtained a developmental disabilities level of care determination from the department within the last thirty calendar days, or, at the time of prior authorization assessment for ventilator services, be determined by the department to meet the criteria for a developmental disabilities level of care in accordance with rule 5123:2-8-01 of the Administrative Code.

(3) Require the use of an invasive mechanical ventilator.

(4) Have been either:

(a) An adult resident of an ICFIID approved to provide pediatric ventilator services on the day immediately prior to the effective day of this rule; or

(b) An inpatient, for at least ninety days within the past twelve months, in an acute care hospital for treatment of a life-threatening or complex medical condition. If the individual has been an inpatient in an acute care hospital for treatment of a life-threatening or complex medical condition within the past twelve months but for less than ninety days, an ICFIID may submit to the department, and the department may approve, a written request to waive the ninety-day requirement. The request shall include a description of the clinical services the individual continues to require and an attestation by the ICFIID that it is able to meet the individual's needs.

(5) Have achieved a stabilized medical condition so that the immediate services of an acute care hospital, including daily physician visits, are not medically necessary.

(6) Require monitoring by a nurse twenty-four hours per day and professional assessment by a registered nurse on a daily basis.

(D) ICFIID eligibility criteria

(1) An ICFIID shall complete and submit to the department an application for approval to provide ventilator services. The application is available at the department's website (http://dodd.ohio.gov/). The ICFIID shall provide any additional information requested by the department and may be subject to documentation review and on-site visits by department personnel.

(2) In order to be approved to provide ventilator services and qualify for enhanced payment for provision of ventilator services to prior-authorized individuals, an ICFIID shall:

(a) Be an Ohio medicaid-certified ICFIID and agree to cooperate with the department's oversight of ventilator services;

(b) Meet the requirements set forth in rule 5123:2-7-02 of the Administrative Code in order to obtain and maintain a provider agreement.

(c) Fully meet all standards for residential facilities licensed in accordance with section 5123.19 of the Revised Code or have an approved and implemented plan of correction and have not demonstrated a pattern of repeat deficiencies.

(d) Fully meet all standards for Ohio medicaid ICFIID certification or meet the medicaid program requirements of a facility for which the Ohio department of health found deficiencies, have an approved and implemented plan of correction, and have not demonstrated a pattern of repeat deficiencies.

(e) Have:

(i) An emergency action plan in place in the event of a power failure;

(ii) An on-site backup generator service for all equipment including suction lines, oxygen lines, and emergency power to ventilators;

(iii) Sufficient backup ventilators on-site and available in the event of mechanical failure as well as any other equipment necessary to meet the needs of individuals in the event of an emergency; and

(iv) An emergency response plan in place in the event of natural or human-made disasters that provides for the safe transport of individuals to a safe area with appropriate resources available to ensure the health and safety of the individuals.

(f) Schedule direct care staff to ensure that adequately trained staff are present and on duty twenty-four hours per day, every day of the year. Staffing shall be sufficient to ensure that urgent, emergent, and routine resident needs are identified appropriately and in a timely manner and are met through the implementation of intervention strategies reflected in each resident's individual plan. Absences of staff for breaks and meals shall not compromise this staffing arrangement.

(g) Ensure that staff who manage ventilator services have evidence of at least two years of work experience with individuals who have complex medical conditions.

(h) Address through staff training programs, the specific medical domains a staff member must master for a thorough understanding and demonstration of competency in order to meet the specialized needs of residents requiring ventilator services. Initial and continuing direct care staff training shall include:

(i) Orientation to the ICFIID's status as a provider of ventilator services, including the individual eligibility criteria set forth in paragraph (C) of this rule and the ICFIID eligibility criteria set forth in paragraph (D) of this rule;

(ii) Information about the specific health care needs of the current residents of the ICFIID who receive ventilator services;

(iii) Accepted best practices and innovative approaches to meet residents' needs;

(iv) Training to ensure nursing care competence for residents, including specialized training on developmental needs that improve an individual's overall functional status; and

(v) Due to the increased risk of infection for residents of ICFIID who receive ventilator services, steps to be taken to minimize risk of transmission of contagious or infectious diseases.

(i) Agree to furnish or arrange to have furnished all medically necessary services to individuals who are dependent on invasive mechanical ventilators, regardless of whether the services are reimbursable through the ICFIID cost report mechanism or directly to the provider of such services.

(i) The ICFIID shall ensure that physician services are available twenty-four hours per day.

(ii) A physician shall complete an assessment of the individual at least once every thirty calendar days for the first ninety calendar days and at least once every ninety calendar days thereafter if the individual maintains a stable status with no acute complications related to ventilator support. If acute care needs requiring hospitalization present upon return to the ICFIID, a physician shall complete an assessment of the individual at least once every thirty calendar days for the first ninety calendar days and at least once every ninety calendar days thereafter.

(iii) The ICFIID shall ensure that respiratory care services are available twenty-four hours per day. Medically necessary respiratory care services shall be provided by a respiratory care professional or by a nurse who the ICFIID has determined has the training, knowledge, skill, and ability to complete the services in coordination with the respiratory care professional, and as ordered by a physician.

(iv) The ICFIID, in consultation with a physician and a respiratory care professional, shall develop a facility plan for providing care to individuals who are dependent on invasive mechanical ventilators. The plan shall address maintenance of ventilators, required modification and maintenance of facilities, and special accommodations required to ensure that all needs, including but not limited to, hygiene, bathing, dietary, social, and transportation, of individuals who are dependent on invasive mechanical ventilators, are met.

(v) The ICFIID shall ensure that services by registered nurses are available twenty-four hours per day.

(vi) Nursing care and any personal care that may be required for the health, safety, and wellbeing of the individuals served shall be available twenty-four hours per day. Nursing personnel shall be sufficient to ensure prompt recognition of any adverse change in an individual's condition and to facilitate nursing, medical, or other appropriate interventions, up to and including transfers to an acute care hospital.

(vii) The need for physical, occupational, and/or speech therapy services shall be assessed and services shall be provided as needed by therapists licensed to practice in Ohio.

(viii) If an individual is receiving enteral feedings and there is a complication of medical status secondary to the nutritional status, a dietary consultation by a person licensed to practice dietetics in Ohio shall be made available to that individual.

(j) Prior to admission of an individual who requires ventilator services, arrange for a suitable school or day program for the individual and submit the plan for such program to the designated outlier coordinator or other department designee.

(k) Prior to admission of an individual who requires ventilator services, develop and submit to the designated outlier coordinator or other department designee accurate assessments or reassessments by an interdisciplinary team that address the individual's health, social, psychological, educational, vocational, and chemical dependency needs. Health information shall include a copy of the medical assessment completed by a physician who has knowledge of and experience with the individual and shall include a clinical summary, need for invasive mechanical ventilation (including viability and plan for weaning), detailed therapy assessment with recommended therapy plan, medication needs, and any other medical information relevant to the individual's care needs.

(l) Ensure that a registered nurse submits a written summary of clinical status to the primary care physician on a monthly basis. The physician shall review and sign the summary and place it in the individual's medical record.

(m) Due to the complex and intensive needs of individuals who require ventilator services, develop a transitional plan prior to admission of an individual to ensure that the ICFIID is able to meet the individual's health, safety, and behavioral support needs from the day of admission. The transitional plan shall address major concerns and shall be provided to the designated outlier coordinator or other department designee upon request.

(n) Within thirty calendar days after admission, develop accurate assessments or reassessments by an interdisciplinary team that address the individual's health, social, psychological, educational, vocational, and chemical dependency needs in order to supplement the preliminary evaluation described in paragraph (D)(2)(k) of this rule, which was conducted prior to admission. The ICFIID shall provide the assessments or reassessments to the designated outlier coordinator or other department designee upon request.

(o) Develop a comprehensive individual plan within thirty calendar days of an individual's admission, with input from the individual, the individual's parent, the individual's guardian, or other person whom the individual has identified, as applicable. The ICFIID shall provide a copy of the individual plan to the designated outlier coordinator or other department designee upon request.

(i) The individual plan shall be reviewed by the appropriate program staff at least quarterly and revised as necessary with input from the individual, the individual's parent, the individual's guardian, or other person whom the individual has identified, as applicable.

(ii) The ICFIID shall notify the designated outlier coordinator or other department designee whenever an individual experiences a significant change in medical status, including hospitalization.

(iii) The ICFIID shall prepare a quarterly report in a format approved by the department that summarizes the resident's individual plan, progress, changes in treatment, current status relative to discharge goals, and any updates to the discharge plan, including referrals made and anticipated time frames. The ICFIID shall provide a copy of the quarterly report to the designated outlier coordinator or other department designee upon request.

(iv) The designated outlier coordinator or other department designee may visit the ICFIID at any time. The ICFIID shall provide any documents or information requested by the designated outlier coordinator or other department designee.

(p) Within thirty calendar days after admission, develop a written discharge plan with the interdisciplinary team in conjunction with the individual and others concerned with the individual's welfare. The discharge plan shall include a description of targeted medical/health status indicators that would signify the resident could be safely discharged. The ICFIID shall provide a copy of the discharge plan to the designated outlier coordinator or other department designee upon request.

(q) Accept payment for the provision of services at the non-outlier ICFIID reimbursement rate if prior authorization for ventilator services requested for an individual already residing in the ICFIID is denied.

(E) Outlier per diem rate

(1) An ICFIID's per diem rate shall be set in accordance with Chapter 5124. of the Revised Code and applicable rules in Chapter 5123:2-7 of the Administrative Code. An outlier per diem rate for ventilator services, determined and applied in accordance with paragraph (H) of this rule, shall be added to the ICFIID's per diem rate.

(2) With the exception of any specific items that are direct-billed in accordance with rule 5123:2-7-11 of the Administrative Code, the ICFIID shall agree to accept as payment in full the per diem rate established for ventilator services in accordance with this rule, and to make no additional charge to the individual, to any member of the individual's family, or to any other source for covered ventilator services.

(F) Prior authorization for services

(1) Payment for ventilator services covered by the medicaid program shall be available only upon prior authorization by the department for each individual in accordance with the procedures set forth in this rule. The prior authorization procedures set forth in this rule are in addition to the developmental disabilities level of care review process set forth in rule 5123:2-8-01 of the Administrative Code.

(a) Unless the individual is seeking a change of payer, prior authorization for ventilator services shall occur prior to admission to the ICFIID.

(b) In the case of requests for continued stay, prior authorization for ventilator services shall occur no later than the final day of the previously authorized ventilator services stay.

(2) A request for prior authorization for ventilator services shall be submitted to the department in writing via email to cr-icf@dodd.ohio.gov.

(3) It is the responsibility of the ICFIID to ensure that all required information is provided to the department as requested. An initial request for prior authorization for ventilator services is considered complete when:

(a) A request has been accurately completed and submitted via email to cr-icf@dodd.ohio.gov;

(b) A developmental disabilities level of care has been issued in accordance with rule 5123:2-8-01 of the Administrative Code and a determination regarding the feasibility of community-based care has been made; and

(c) The designated outlier coordinator has received supporting documentation exhibiting evidence that the applicant meets the eligibility criteria set forth in paragraphs (C)(3) to (C)(6) of this rule. The ICFIID shall retain a duplicate copy of all submitted documentation. Supporting documentation may include, but is not limited to, the preliminary evaluation, assessments, and transitional plan required prior to admission as set forth in paragraph (D) of this rule.

(4) The department's determination shall be based on the completed initial stay request and any additional information or documentation necessary to make the determination of eligibility for ventilator services, which may include a face-to-face visit by at least one department representative with the individual and, if applicable, the individual's parent, the individual's guardian, or other person whom the individual has identified and, to the extent possible, the individual's formal and informal care givers, to review and discuss the individual's care needs and preferences.

(5) Based upon a comparison of the individual's condition, service needs, and the requested placement site with the eligibility criteria set forth in paragraph (C) of this rule, the department shall conduct a review of the application, assessment report, and supporting documentation about the individual's condition and service needs to determine whether the individual is eligible for ventilator services.

(6) The department shall issue a notice of determination within thirty calendar days of receipt of a complete request for prior authorization indicating approval or denial of the request to the individual, the individual's parent, the individual's guardian, or other person whom the individual has identified, as applicable, and the ICFIID. The department shall send a copy of the notice to the county department of job and family services to be maintained in the individual's case record.

(a) When a request for prior authorization for ventilator services is denied, notice shall specify the reason for denial and explain the individual's right to a state hearing in accordance with section 5101.35 of the Revised Code.

(b) When a request for prior authorization for ventilator services is approved, the notice shall include an assigned prior authorization number, the number of days for which ventilator services are authorized, and the date on which payment is authorized to begin. The notice shall also include the name, location, and phone number of the department staff member who is assigned to monitor the individual's progress at the ICFIID.

(i) Individuals who are determined to have met the eligibility criteria set forth in paragraph (C) of this rule may be approved for an initial stay of a maximum of one hundred eighty-four days. The number of days prior-authorized for each eligible individual shall be based upon the submitted application materials, consultation with the individual's attending physician, and/or any additional consultations or materials required by the assessor to make a reasonable estimation regarding the individual's probable need for ventilator services.

(ii) Continued stay determinations shall be based on reports from the ICFIID submitted to the designated outlier coordinator regarding critical events and the status of the individual's condition and discharge planning options, face-to-face assessments conducted by the department, and/or other information determined by the department. When the department determines that the individual continues to meet the eligibility criteria set forth in paragraph (C) of this rule, and the ICFIID submits a request for continued stay in accordance with paragraph (F)(8) of this rule, continued stays may be approved for maximum increments of one hundred eighty-four days.

(c) Reimbursement for ventilator services shall be limited to services approved as indicated in the approval letter.

(7) An individual is expected to be discharged to the setting specified in the individual's discharge plan at the end of the prior-authorized initial or continued stay, and progress toward that end shall be monitored by the department or its designee throughout the individual's stay in the ICFIID.

(8) Ventilator services may be extended beyond the previously approved length of stay if the ICFIID submits a written request to the department proving that it is not possible to implement the individual's discharge plan. Such requests shall be submitted at least thirty calendar days prior to the last day of the previously authorized stay, unless there is a significant change of circumstances within the week preceding the expected discharge date that prevents implementation of the discharge plan.

(G) Payment authorization

The payment authorization date shall be one of the following, but shall not be earlier than the effective date of the individual's developmental disabilities level of care determination:

(1) The date of admission to the ICFIID; or

(2) The date of prior authorization for ventilator services approval, if the individual was already a resident of an ICFIID that provides ventilator services but was using another payer source.

(H) Initial and subsequent contracted rates

(1) The department shall establish the initial and subsequent contracted rates in accordance with Chapter 5124. of the Revised Code. All rate adjustments determined in accordance with this rule shall be effective on the payment authorization date determined in accordance with paragraph (G) of this rule through the date of discharge from the ICFIID or until the date the individual no longer meets the eligibility criteria set forth in paragraph (C) of this rule.

(2) An ICFIID may bill the ventilator services revenue code for each individual whose initial or continued stay prior authorization has been approved in accordance with paragraph (F) of this rule.

(3) An ICFIID shall not bill the ventilator services revenue code for individuals who are using bed-hold days in accordance with rule 5123:2-7-08 of the Administrative Code.

(4) The ICFIID shall be responsible for contacting the designated outlier coordinator no later than by the close of the next business day following the discharge of an individual or point at which the individual no longer meets the eligibility criteria established in paragraph (C) of this rule to ensure processing time for recalculation and application of the ventilator services outlier per diem rate to the ICFIID per diem rate.

(5) The ventilator services outlier per diem rate will be specific to the individual approved to receive ventilator services in the amount of three hundred dollars.

(I) Implementation of this rule

For purposes of implementation and notwithstanding other provisions of this rule:

(1) A resident of an ICFIID who was receiving pediatric ventilator services on the day immediately prior to the effective date of this rule shall be deemed by the department to be prior-authorized to receive ventilator services in accordance with this rule.

(2) An ICFIID that was approved to provide pediatric ventilator services on the day immediately prior to the effective date of this rule shall be deemed by the department to be approved to provide ventilator services in accordance with this rule.

(3) An ICFIID that was approved to provide pediatric ventilator services on the day immediately prior to the effective date of this rule, seeking to secure prior authorization for ventilator services on behalf of an adult individual who was a resident of the ICFIID on the day immediately prior to the effective date of this rule, shall submit to the department in writing via email to cr-icf@dodd.ohio.gov:

(a) The individual's comprehensive individual plan which includes a suitable day program, developed with input from the individual, the individual's guardian, or other person whom the individual has identified, as applicable.

(b) Accurate assessments or reassessments by an interdisciplinary team that address the individual's health, social, psychological, educational, vocational, and chemical dependency needs. Health information shall include a copy of the medical assessment completed by a physician who has knowledge of and experience with the individual and shall include a clinical summary, need for invasive mechanical ventilation (including viability and plan for weaning), detailed therapy assessment with recommended therapy plan, medication needs, and any other medical information relevant to the individual's care needs.

(c) A written discharge plan developed with the interdisciplinary team in conjunction with the individual and others concerned with the individual's welfare. The discharge plan shall include a description of targeted medical/health status indicators that would signify the resident could be safely discharged.

(d) Other documents or information requested by the department for purposes of making a determination.

(4) The department shall issue a notice of determination within ten calendar days of receipt of a complete request for prior authorization submitted in accordance with paragraph (I)(3) of this rule. When the department determines the individual is eligible for ventilator services, the payment authorization date shall be the date of prior authorization for ventilator services approval.

Supplemental Information

Authorized By: 5123.04, 5124.03, 5124.152
Amplifies: 5123.04, 5124.03, 5124.15, 5124.152, 5124.25, 5162.021
Five Year Review Date: 1/18/2023
Rule 5123:2-7-31 | Intermediate care facilities for individuals with intellectual disabilities - recoupment of downsizing incentive.
 

(A) Purpose

This rule establishes a process for the recoupment of a downsizing incentive from an intermediate care facility for individuals with intellectual disabilities (ICFIID) when the ICFIID obtained department approval to become a downsized ICFIID pursuant to section 5124.39 of the Revised Code and does not become a downsized ICFIID on or before July 1, 2018.

(B) Definitions

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

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

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

(C) Amount of recoupment

(1) On or before January 1, 2018, the department shall survey each ICFIID with an approved downsizing plan to determine if the ICFIID will in fact become a downsized ICFIID on or before July 1, 2018. An ICFIID shall respond to the department in writing on or before February 1, 2018.

(2) When the department determines that the ICFIID will not become a downsized ICFIID on or before July 1, 2018, the department shall calculate the amount of the recoupment in accordance with division (A)(1) of section 5124.39 of the Revised Code and send notice to the ICFIID by registered mail, return receipt requested, of the amount due.

(3) The amount of the recoupment calculated in accordance with paragraph (C)(2) of this rule shall be due and payable as of July 1, 2018.

(D) Interest

(1) Except as provided in paragraph (D)(2) of this rule, the department shall charge interest on the amount of the recoupment that is equal to the current average bank prime rate as determined pursuant to section 5124.43 of the Revised Code. Interest on the amount shall begin to accrue from the date the rate was calculated based on the ICFIID's approved downsizing plan.

(2) The department shall not charge interest on the amount of the recoupment when:

(a) An ICFIID voluntarily repays the amount determined by the department to be subject to recoupment; or

(b) An ICFIID voluntarily repays the amount determined by the department to be subject to recoupment when it reports to the department in writing on or before February 1, 2018 that it will not become a downsized ICFIID on or before July 1, 2018, and notifies the department of the method of repayment in accordance with paragraph (E)(2) of this rule.

(E) Payment methods

(1) On or before July 1, 2018, an ICFIID subject to recoupment shall notify the department in writing of the desired method by which to make the repayment.

(2) The repayment may be made:

(a) In a lump sum payment to the department;

(b) In a single deduction from the ICFIID's next scheduled medicaid payment as long as the deduction will equal the total amount due to the department;

(c) Pursuant to a written agreement between the department and the ICFIID, in installment payments to the department for a period not to exceed six months; or

(d) Pursuant to a written agreement between the department and the ICFIID, in installment deductions from the ICFIID's next scheduled medicaid payments for a period not to exceed six months.

(3) The department's decision to allow or disallow repayment by the methods described in paragraphs (E)(2)(c) and (E)(2)(d) of this rule is final and not subject to appeal.

(F) Request for exemption from recoupment

(1) On or before July 1, 2018, an ICFIID subject to recoupment may request in writing that the department exempt it from recoupment by providing proof to the department that:

(a) The ICFIID made a good faith effort to become a downsized ICFIID in accordance with its approved plan by July 1, 2018, but was unable to complete the downsizing for reasons beyond the ICFIID's control; and

(b) The ICFIID provides the department with a plan and timeline to ensure that the ICFIID becomes a downsized ICFIID within a reasonable period of time after July 1, 2018.

(2) The department shall consider all of the information submitted by the ICFIID and issue a written decision regarding the exemption from recoupment within thirty calendar days of receiving the request.

(3) Subject to the provisions of paragraph (H) of this rule, the department's decision to allow or disallow the request for exemption from recoupment is final and not subject to further appeal.

(G) Nonconformity with terms of exemption from recoupment

If an ICFIID receives an exemption from recoupment in accordance with paragraph (F) of this rule and fails to become a downsized ICFIID on or before the date set forth in the approved exemption:

(1) The department shall calculate the amount of the recoupment in accordance with division (A)(1) of section 5124.39 of the Revised Code and send notice to the ICFIID by registered mail, return receipt requested, of the amount due.

(2) The amount of the recoupment calculated in accordance with paragraph (G)(1) of this rule shall be due and payable no later than ten calendar days after the ICFIID receives notice of the amount due.

(3) The department shall charge interest on the amount of the recoupment that is equal to the current average bank prime rate as determined pursuant to section 5124.43 of the Revised Code. Interest on the amount shall begin to accrue from the date the rate was calculated based on the ICFIID's original approved downsizing plan.

(4) Paragraph (D)(2) of this rule shall not apply.

(H) Request for reconsideration

(1) An ICFIID may submit a written request for reconsideration to the department no later than ten calendar days after it receives the notice of recoupment pursuant to paragraph (C) or (G) of this rule. The request for reconsideration may ask the department to reconsider that the ICFIID is subject to recoupment or may ask the department to reconsider the amount of the recoupment.

(2) The department shall consider all of the information submitted by the ICFIID and issue a written decision regarding reconsideration within thirty calendar days of receiving the request.

(3) The department's decision regarding the request for reconsideration is final and not subject to further appeal.

Supplemental Information

Authorized By: 5123.04, 5124.03, 5124.39
Amplifies: 5123.04, 5124.03, 5124.39
Five Year Review Date: 7/1/2022
Rule 5123:2-7-32 | Intermediate care facilities for individuals with intellectual disabilities - administration of the Ohio developmental disabilities profile.
 

(A) Purpose

This rule sets forth a requirement and process for administration of the Ohio developmental disabilities profile to residents of an intermediate care facility for individuals with intellectual disabilities (ICFIID).

(B) Definitions of terms used in this rule

(1) "Certified assessor" means a person authorized by the department to administer the Ohio developmental disabilities profile. In order to become a certified assessor, a person shall complete training conducted or approved by the department and successfully perform a post-training demonstration.

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

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

(4) "Ohio developmental disabilities profile" means the instrument used to assess the needs and circumstances of an individual with developmental disabilities relative to other individuals with developmental disabilities.

(5) "Reporting period" means one of the four quarters of the calendar year, that is:

(a) January through March;

(b) April through June;

(c) July through September; or

(d) October through December.

(6) "Reporting period end date" means the last day of the last month in a reporting period.

(7) "Significant change of condition" means that the individual has experienced a change in physical or mental condition or functional abilities which may result in a change in the individual's support needs.

(C) Administration of the Ohio developmental disabilities profile

(1) Only a certified assessor may administer the Ohio developmental disabilities profile or attest that the most recent Ohio developmental disabilities profile is still valid for a resident of an ICFIID.

(2) A certified assessor of the department shall administer the Ohio developmental disabilities profile to a new resident of an ICFIID (other than a resident who transfers from another ICFIID) within thirty calendar days of the resident's admission, regardless of the resident's payment source or anticipated length of stay. Within seven calendar days of administration of the Ohio developmental disabilities profile, the department shall electronically notify the ICFIID of the results.

(3) When a resident of an ICFIID transfers to another ICFIID, the resident's most recent Ohio developmental disabilities profile shall transfer with the resident.

(4) When a resident of an ICFIID, regardless of the resident's payment source or anticipated length of stay, experiences a significant change of condition, a certified assessor of the ICFIID shall administer the Ohio developmental disabilities profile and electronically submit the results to the department with supporting documentation for the significant change of condition within fifteen calendar days of the significant change of condition. Within seven calendar days of receipt of the ICFIID's electronic submission, the department shall make a determination on a question-by-question basis and electronically notify the ICFIID that:

(a) The department accepts the results of the Ohio developmental disabilities profile administered by the ICFIID;

(b) The department requires additional supporting documentation to make a determination which shall be submitted by the ICFIID within seven calendar days; or

(c) The department does not accept the results of the Ohio developmental disabilities profile administered by the ICFIID with the department's rationale for not accepting the results.

(5) An ICFIID that disputes the results of an Ohio developmental disabilities profile administered by the department in accordance with paragraph (C)(2) of this rule or the department's determination in accordance with paragraph (C)(4)(c) of this rule may submit a request for reconsideration within fifteen calendar days of receiving notification of the results or determination. The ICFIID shall electronically submit the request for reconsideration to the department with a detailed explanation of why the ICFIID disputes the results or determination, relevant supporting documentation, and a proposed resolution. When an ICFIID submits a request for reconsideration in response to the department's determination in accordance with paragraph (C)(4)(c) of this rule, a certified assessor of the department shall re-administer the entire Ohio developmental disabilities profile to the resident. The department shall electronically respond to the ICFIID within fifteen calendar days of receiving the request for reconsideration. The department's decision regarding a request for reconsideration is final and not subject to further appeal.

(D) Quarterly certification of Ohio developmental disabilities profile data

(1) For each reporting period, a certified assessor of the ICFIID shall attest that the most recent Ohio developmental disabilities profile is still valid for each resident of the ICFIID on the reporting period end date, regardless of a resident's payment source or anticipated length of stay.

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

(i) 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

(ii) 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.

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

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

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

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

(2) A certified assessor of the ICFIID shall electronically certify the Ohio developmental disabilities profile data on behalf of the entire ICFIID no later than fifteen calendar days following the reporting period end date. The certification shall include the name of the certified assessor who verified that an Ohio developmental disabilities profile has been administered and attested that the most recent Ohio developmental disabilities profile is still valid for each resident of the ICFIID on the reporting period end date and the name and contact information of a staff member should department staff have questions about the data.

(E) Summary and correction of Ohio developmental disabilities profile data

(1) The department shall electronically notify an ICFIID of a missing or incomplete certification of Ohio developmental disabilities profile.

(2) The department shall process and summarize the ICFIID's Ohio developmental disabilities profile data for the reporting period and electronically provide a summary of the data to the ICFIID.

(3) An ICFIID may correct errors or omissions identified by either the department or the ICFIID by electronically submitting corrections along with an amended certification of Ohio developmental disabilities profile data no later than forty-five calendar days following the reporting period end date. Timeliness of the submission shall be determined by the electronic submission date.

(4) An ICFIID shall ensure that corrections made to the Ohio developmental disabilities profile data submitted to the department are consistent with the Ohio developmental disabilities profiles maintained at the ICFIID.

Supplemental Information

Authorized By: Section 261.170 of House Bill 49 of the 132nd General Assembly, 5124.03, 5123.04
Amplifies: 5123.04, Section 261.170 of House Bill 49 of the 132nd General Assembly, 5124.03
Five Year Review Date: 9/15/2022