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Section 5165.26 | Nursing facility's per medicaid day quality incentive payment rate.

Ohio Revised Code
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Title 51 Public Welfare
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Chapter 5165 Medicaid Coverage Of Nursing Facility Services
 
You are viewing a past version of this section that is no longer in effect View Current Version
Effective:
October 17, 2019
Legislation:
House Bill 166 - 133rd General Assembly
PDF:
Download Authenticated PDF
 

(A) As used in this section:

(1) "Base rate" means the portion of a nursing facility's total per medicaid day payment rate determined under divisions (A) and (B) of section 5165.15 of the Revised Code.

(2) "CMS" means the United States centers for medicare and medicaid services.

(3) "Long-stay resident" and "measurement period" have the same meanings as in section 5165.25 of the Revised Code.

(B) For the second half of state fiscal year 2020 and all of each state fiscal year thereafter, and subject to divisions (D) and (E) of this section, the department of medicaid shall determine each nursing facility's per medicaid day quality incentive payment rate as follows:

(1) Determine the sum of the quality scores determined under division (C) of this section for all nursing facilities.

(2) Determine the average quality score by dividing the sum determined under division (B)(1) of this section by the number of nursing facilities for which a quality score was determined.

(3) Determine the following:

(a) For the second half of state fiscal year 2020, the sum of the total number of medicaid days for the second half of calendar year 2018 for all nursing facilities for which a quality score was determined;

(b) For all of state fiscal year 2021 and each state fiscal year thereafter, the sum of the total number of medicaid days for the measurement period applicable to the state fiscal year for all nursing facilities for which a quality score was determined.

(4) Multiply the average quality score determined under division (B)(2) of this section by the sum determined under division (B)(3) of this section.

(5) Determine the value per quality point by determining the quotient of the following:

(a) The following:

(i) For the second half of state fiscal year 2020, the sum determined under division (E)(1)(b) of this section;

(ii) For all of state fiscal year 2021 and each state fiscal year thereafter, the sum determined under division (E)(2)(b) of this section.

(b) The product determined under division (B)(4) of this section.

(6) Multiply the value per quality point determined under division (B)(5) of this section by the nursing facility's quality score determined under division (C) of this section.

(C)(1) Except as provided in divisions (C)(2) and (3) of this section, a nursing facility's quality score for a state fiscal year shall be the sum of the total number of points that CMS assigned to the nursing facility under CMS's nursing facility five-star quality rating system for the following quality metrics:

(a) The percentage of the nursing facility's long-stay residents at high risk for pressure ulcers who had pressure ulcers during the measurement period;

(b) The percentage of the nursing facility's long-stay residents who had a urinary tract infection during the measurement period;

(c) The percentage of the nursing facility's long-stay residents whose ability to move independently worsened during the measurement period;

(d) The percentage of the nursing facility's long-stay residents who had a catheter inserted and left in their bladder during the measurement period.

(2) In determining a nursing facility's quality score for a state fiscal year, the department shall make the following adjustment to the number of points that CMS assigned to the nursing facility for each of the quality metrics specified in division (C)(1) of this section:

(a) Unless division (C)(2)(b) of this section applies, divide the number of the nursing facility's points for the quality metric by twenty.

(b) If CMS assigned the nursing facility to the lowest percentile for the quality metric, reduce the number of the nursing facility's points for the quality metric to zero.

(3) A nursing facility's quality score shall be zero for a state fiscal year if it is not to receive a quality incentive payment for that state fiscal year because of division (D) of this section.

(D)(1) Except as provided in division (D)(2) of this section, a nursing facility shall not receive a quality incentive payment for a state fiscal year, other than the second half of state fiscal year 2020, if the nursing facility's licensed occupancy percentage is less than eighty per cent.

(2) Division (D)(1) of this section does not apply to a nursing facility for a state fiscal year if either of the following apply:

(a) The nursing facility has a quality score under division (C) of this section for the state fiscal year of at least fifteen points;

(b) The nursing facility was initially certified for participation in the medicaid program.

(3) A nursing facility's licensed occupancy percentage for a state fiscal year shall be determined as follows:

(a) Multiply the nursing facility's licensed capacity on the last day of the measurement period applicable to the state fiscal year by the number of days in that measurement period;

(b) Divide the number of the nursing facility's inpatient days for the measurement period applicable to the state fiscal year by the product determined under division (D)(3)(a) of this section.

(E) The total amount to be spent on quality incentive payments for a state fiscal year shall be the following:

(1) For the second half of state fiscal year 2020, the amount determined as follows:

(a) Determine the following amount for each nursing facility, including those that do not receive a quality incentive payment because of division (D) of this section:

(i) The amount that is two and four-tenths per cent of the nursing facility's base rate for nursing facility services provided on January 1, 2020;

(ii) Multiply the amount determined under division (E)(1)(a)(i) of this section by the number of the nursing facility's medicaid days for the second half of calendar year 2018.

(b) Determine the sum of the products determined under division (E)(1)(a)(ii) of this section for all nursing facilities for which the product was determined for the second half of state fiscal year 2020.

(2) For all of state fiscal year 2021 and each state fiscal year thereafter, the amount determined as follows:

(a) Determine the following amount for each nursing facility, including those that do not receive a quality incentive payment because of division (D) of this section:

(i) The amount that is two and four-tenths per cent of the nursing facility's base rate for nursing facility services provided on the first day of the state fiscal year;

(ii) Multiply division (E)(2)(a)(i) of this section by the number of the nursing facility's medicaid days for the measurement period applicable to the state fiscal year.

(b) Determine the sum of the products determined under division (E)(2)(a) of this section for all nursing facilities for which the product was determined for the state fiscal year.

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