Ohio Administrative Code Search

...(A) The purpose of this rule is to set forth the definitions for terms contained in rules 5160-3-15.1, 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code. (B) Definitions: (1) "Adverse determination" means a determination made in accordance with rules 5160-3-15.1, 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code, that an individual does not require the level of se...

...(A) The purpose of this rule is to set forth the level I and level II preadmission screening requirements pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019, to ensure that individuals seeking admission, as defined in rule 5160-3-15 of the Administrative Code, to a medicaid-certified nursing facility (NF) who have serious mental illness (SMI) and/or a developmenta...

...(A) The purpose of this rule is to set forth resident review requirements in compliance with section 1919(e)(7) of the Social Security Act, as in effect on July 1, 2019, which prohibits nursing facilities (NF) from retaining individuals with serious mental illness (SMI) as defined in rule 5160-3-15 of the Administrative Code and/or developmental disabilities (DD) as defined in rule 5160-3-15 of th...

...(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) Rei...

...(A) Definitions. (1) "Home and community-based services" (HCBS) means services that enable individuals to live in a community setting rather than in an institutional setting such as a NF, an intermediate care facility for individuals with intellectual disabilities (ICF-IID), or a hospital. (2) "Hospitalization" means transfer of a NF resident to a medical institution as defined in paragraph (A)(4) of this rule. A N...

...(A) Purpose. In accordance with section 5165.157 of the Revised Code, this rule establishes an alternative purchasing model for the provision of nursing facility (NF) services to ventilator dependent individuals which may include ventilator weaning. (B) Definitions. For purposes of this rule the following definitions apply: (1) "Discrete unit" means an area in a NF that is set aside from the l...

...This rule identifies covered services generally available to medicaid recipients and describes the relationship of such services to those provided by a NF. Whenever reference is made to payment for services through the NF per diem, the rules governing such payment are set forth in Chapter 5160-3 of the Administrative Code. (A) Acupuncture services. All covered acupuncture services provided by an eligibl...

...In addition to the provisions contained in sections 5165.10 to 5165.109 of the Revised Code, the following provisions apply. (A) For reporting purposes NFs shall use the chart of accounts for NFs as set forth in rule 5160-3-42 of the Administrative Code, or relate its chart of accounts directly to the cost report. (B) Unless an extension is granted by the Ohio department of medicaid (ODM), NF cost...

...(A) When submitting an appeal of a FPF determination or re-determination for a nursing home or hospital long term care unit in accordance with section 5168.53 of the Revised Code, a facility operator shall follow these procedures: (1) The appeal shall be in writing and must be received by the Ohio department of medicaid (ODM) not later than fifteen days after the date on which the FPF assessment notice was mailed. ...

...(A) Definitions. "Effective FPF termination date" (EFTD) means the date on which the centers for medicare and medicaid services (CMS) determines that the FPF does not qualify for federal financial participation. (B) Determination of the FPF as an impermissible health care related tax. If CMS determines that the FPF is an impermissible health care related tax, the Ohio department of medicaid (OD...

...(A) The Ohio department of medicaid (ODM) shall use the debt estimation methodology set forth in this rule to estimate the exiting operator's actual and potential debts to ODM and the United States centers for medicare and medicaid services (CMS) under the medicaid program in cases of a change of operator, facility closure, voluntary termination, involuntary termination, or voluntary withdrawal. ...

...(A) The Ohio department of medicaid (ODM) uses the debt estimation methodology set forth in this rule to estimate the exiting operator's actual and potential debts to ODM and the United States centers for medicare and medicaid services (CMS) under the medicaid program in cases of a change of operator, facility closure, voluntary termination, involuntary termination, or voluntary withdrawal. (B) O...

...(A) Debt estimate. For the purposes of division (C) of section 5165.52 of the Revised Code, the debt estimate for change of operator, facility closure, voluntary termination, involuntary termination, or voluntary withdrawal is considered provided by the Ohio department of medicaid (ODM) on the date of mailing, date of personal service, or date of publication. (B) Initial debt summary report. (1...

...(A) Forms. For dates of services preceding July 1, 2005, NFs shall submit the form "Nursing Facility Payment and Adjustment Authorization" (JFS 09400, rev. 10/2012) directly to the Ohio department of job and family services (ODJFS) for the reimbursement of services. The county department of job and family services (CDJFS) and NFs shall use the "Facility/CDJFS Transmittal" (JFS 09401, rev. 4/2011) form to exchange i...

...(A) Requirements for submitting claims for services not included in the NF per diem rate. Notwithstanding the requirements set forth in paragraph (A)(2) of rule 5160-1-19 of the Administrative Code, NF providers shall submit medicare crossover claims and claims for medicaid reimbursement for allowable services that are not included in the NF per diem rate in accordance with the requirements set forth in rule 5160-1-...

...(A) Nursing facilities shall submit claims in accordance with rule 5160-1-19 of the Administrative Code. Additional requirements specific to the submission of long-term care per diem claims are in paragraphs (B) to (E) of this rule. (B) Additional requirements to be met prior to submitting claims for services included in the per diem. (1) Individual is a medicaid recipient for the dates of servi...

...(A) The Ohio department of medicaid (ODM) requires that all facilities file cost reports annually to comply with section 5165.10 of the Revised Code. (1) The chart of accounts in table 1 to table 8 of appendix A to this rule is to establish the minimum level of detail to allow for cost report preparation. (2) If the chart of accounts in appendix A to this rule is not used by the provider, it ...

...(A) Depreciation on buildings, components, and equipment used in the provision of patient care that are not reimbursable by medicaid directly to the medical equipment supplier may be paid for through the NF per diem rate. (B) For purposes of determining if an expenditure should be capitalized, NF providers are to refer to the centers for medicare and medicaid services (CMS) publication 15-1, Chap...

...The following costs are not reimbursable to NFs through the NF per diem, except as specified under Chapter 5160-3 of the Administrative Code. Non-reimbursable costs include but are not limited to: (A) Fines or penalties paid under sections 5165.1010, 5165.72 to 5165.77, 5165.83, and 5165.99 of the Revised Code. (B) Disallowances made during the audit of NF cost reports that are sanctioned through adjudication in a...

...(A) As used in this rule: (1) "Annual facility average case mix score" is the score used to calculate the facility's cost per case-mix unit. (2) "Assessment reference date (ARD)" is the last day of the observation (or "look back") period that the MDS 3.0 assessment covers for the resident. (3) "Case mix report" is a report generated by the Ohio department of medicaid (ODM) and distributed t...

...The Ohio department of medicaid (ODM) shall pay each eligible NF a per resident per day rate for direct care costs established prospectively for each facility. The department shall establish each facility's rate for direct care costs semiannually. Each facility's rate for direct care costs shall be based on a case mix payment system. (A) The Ohio medicaid case mix payment system for direct care contains ...

...(A) The definitions of all terms used in this rule are the same as set forth in rules 5160-3-01, 5160-3-43.1, and 5160-3-43.4 of the Administrative Code. (B) To determine resident case mix scores, the Ohio department of medicaid (ODM) shall process resident assessment data submitted by NFs in accordance with rule 5160-3-43.1 of the Administrative Code, and shall classify residents in accordance w...

...(A) Definitions. For purposes of this rule: (1) "Ancillary and support costs," "cost center," "direct care costs," "rebasing" and "tax costs" have the same meaning as in section 5165.01 of the Revised Code. (2) "Cost center report" means a report submitted to the Ohio department of medicaid (ODM) by a nursing facility provider that identifies the amount spent on each cost center included in rebasing. (B) Direct c...

...(A) The Ohio department of medicaid (ODM) shall pay a provider a per medicaid day payment rate for tax costs determined under section 5165.21 of the Revised Code except for the initial rate for new providers. ODM shall determine each new nursing facility's initial per medicaid day payment rate for tax costs in accordance with section 5165.151 of the Revised Code. (B) For purposes of calculating t...

...(A) For nursing facility services the nursing facility provides on or after January 1, 2012, "medicaid maximum allowable amount" means one hundred per cent of the nursing facility's medicaid rate on the date that the service was provided. (B) For qualified medicare beneficiaries (QMB) as defined in rule 5160:1-3-02.1 of the Administrative Code and medicaid consumers admitted to a nursing facility as a medicare part...