Rule 5160-3-16.3 | Nursing facilities (NFs): private rooms.
(A) A NF may provide private room accommodations, if available, as follows:
(1) For a medicaid eligible resident if the resident requires a private room due to medical necessity such as the need for infection control or for therapeutic purposes; or
(2) Semi-private or ward accommodations are not available; or
(3) In accordance with sections 5165.01 and 5165.158 of the Revised Code.
(B) Reimbursement for private rooms
(1) Unless approved for a private room incentive payment pursuant to section 5165.158 of the Revised Code, medicaid payment for private rooms permitted under paragraphs (A)(1) and (A)(2) of this rule will be paid in accordance with section 5165.15 of the Revised Code.
(2) Private room incentive payments pursuant to section 5165.158 of the Revised Code will only be available to approved providers and will be paid an amount in addition to the total per medicaid day payment rate determined for the facility under section 5165.15 of the Revised Code.
(3) Except as otherwise provided herein, medicaid payment for private rooms is considered payment in full, and no supplemental payment may be requested or accepted from a resident or from a resident's authorized representative or family.
(4) Unless approved for a private room incentive payment pursuant to section 5165.158 of the Revised Code, if semiprivate or ward accommodations are available and are offered to a resident but the resident or the resident's representative or family member makes a written request for a private room, the private room will be considered a non-covered service for which the facility may seek supplemental payment from the resident or from the resident's authorized representative or family as follows:
(a) The supplemental payment amount will represent no more than the difference between the charge to a private pay resident for a semiprivate room and the charge to a private pay resident for a private room;
(b) The charge for the private room cannot include charges for services covered by medicaid, whether or not medicaid payment meets a NF's costs for the per diem services;
(c) A NF should detail both monthly and annual supplemental charges, if applicable, on a resident's statement of charges so that the additional cost of a private room is evident to the resident and to the resident's authorized representative and family;
(d) The written request for a private room will be kept in the resident's file; and
(e) The amount of any supplemental payment will not be considered when calculating the resident's patient liability.
(5) Medicaid bed hold payments for individuals in a private room approved by the department pursuant to section 5165.158 of the Revised Code will be paid in accordance with section 5165.34 of the Revised Code. The private room incentive payment will not be used in determining the bed hold payment rate.
(C) Private room incentive payment
(1) Application process
The following information is to be submitted to the Ohio department of medicaid (department) by a NF seeking a private room incentive payment to demonstrate that the room meets the prerequisites identified in section 5165.158 of the Revised Code:
(a) Application in the form and manner prescribed by the department.
(b) List of all NF rooms and their corresponding number of beds, designating the rooms for which private room incentive payment approval is requested and identifying which rooms are category one and category two private rooms as defined in section 5165.158 of the Revised Code.
(c) Floor plan of the entire facility which identifies and shows the location of each private room with the designated room number and designated bathroom. Arrows should indicate the path between each resident room and the bathroom and each resident room and the hallway.
(d) Documentation evidencing the private room meets the criteria in paragraph (C)(2) of section 5165.158 of the Revised Code.
(e) Attestation in the form and manner prescribed by the department that the information submitted by the facility is accurate and truthful.
(2) Approval process
Applications will be held in a pending status in the order received until the centers for medicare and medicaid services (CMS) approves the private room incentive payments and the department determines a NF is qualified for the private room incentive payment.
(a) The department will review all applications and supporting information to determine if a NF is eligible to receive the incentive payment for private rooms.
(b) Additional information may be requested by the department to ensure a NF's eligibility. NFs will have ten business days from the date of the request to provide this additional information. Failure to submit the requested information within ten business days will invalidate the original application submission. NFs with invalidated applications may reapply.
(c) The department reserves the right to conduct on-site visits as part of this process.
(d) Eligible applications will be approved in the order received until the funding limit identified in the Revised Code is reached.
(e) A NF that is approved will receive written authorization from the department including the effective date for the approval.
(f) If a private room is created by surrendering beds, adding space to the NF, or renovating non-bedroom space, the surrender, addition, or renovation, whichever is applicable, does not have to be completed at the time of application but will need to be completed before an application will be approved by the department.
(3) Reconsideration
(a) A NF that submits an application that is denied in full or in part by the department may request a reconsideration.
(i) If an application is approved in part and denied in part, a reconsideration request will proceed on the denied portion only. The approved portion may proceed and is not held pending the outcome of the reconsideration on the denied portion,
(ii) Denied applications or parts of applications will be held in a pending status in the order received until the conclusion of the reconsideration process.
(b) The reconsideration will be conducted by the department director, assistant director, or deputy director over the area where the contestation arose, or their designee, provided the person conducting the reconsideration was not involved in the original decision.
(c) The denial decision will include information about deadlines and supporting documentation needed for submission of the reconsideration.
(i) Deadlines will be no fewer than thirty days from the date on the notice of the denial decision.
(ii) Reconsideration requests and supporting documentation received after the deadline may be considered at the department's discretion.
(d) Reconsideration decisions will not be further reconsidered.
(4) Change of operator.
If a NF notifies the department of its intent to change operator and an application for private room incentive payments is in a pending status, the new operator will not need to reapply and will maintain the NF's order in the pending status. The new operator will need to attest that the original information submitted by the NF is true and accurate and disclose any information that is different from the original application submission.
Last updated September 9, 2024 at 8:50 AM
Supplemental Information