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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You are viewing a past version of this section that is no longer in effect View Current Version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:
June 19, 2020
Legislation:
House Bill 481 - 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) "Force majeure event" means an uncontrollable force or natural disaster not within the power of a nursing facility's operator.

(4) "Long-stay resident" has the same meaning as in section 5165.25 of the Revised Code.

(5) "Nursing facilities for which a quality score was determined" includes nursing facilities that are determined to have a quality score of zero.

(B) For state fiscal year 2021, and subject to divisions (D), (E), and (F) 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) For state fiscal year 2021, determine the sum of the total number of medicaid days for all of calendar year 2019 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) For state fiscal year 2021, the sum determined under division (F)(2) 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 state fiscal year 2021 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 based on the most recent four-quarter average data available in the database maintained by the United States centers for medicare and medicaid services and known as nursing home compare in May of 2020:

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

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

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

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

(2) In determining a nursing facility's quality score for state fiscal year 2021, 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 state fiscal year 2021 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 state fiscal year 2021 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 if any of the following apply:

(a) The nursing facility has a quality score under division (C) of this section for state fiscal year 2021 of at least fifteen points;

(b) The nursing facility was initially certified for participation in the medicaid program on or after January 1, 2019;

(c) Subject to division (D)(4) of this section, one or more of the beds that are part of the nursing facility's licensed capacity could not be used for resident care during calendar year 2019 due to causes beyond the reasonable control of the nursing facility's operator, including a force majeure event;

(d) Subject to division (D)(5) of this section, the nursing facility underwent a renovation during the period beginning January 1, 2018, and ending January 1, 2020, to which both of the following apply:

(i) The renovation involved capital expenditures of at least fifty thousand dollars, excluding expenditures for equipment, staffing, or operational costs.

(ii) The renovation directly impacted the area of the nursing facility in which the beds that are part of the nursing facility's licensed capacity are located.

(3) A nursing facility's licensed occupancy percentage for the purpose of division (D)(1) of this section shall be determined as follows:

(a) Determine the product of the following:

(i) The nursing facility's licensed capacity as of December 31, 2019, as identified on the nursing facility's cost report filed with the department pursuant to section 5165.10 of the Revised Code;

(ii) Three hundred sixty-five.

(b) Determine the quotient of the following:

(i) The total number of the nursing facility's inpatient days for calendar year 2019, as identified on the nursing facility's cost report filed with the department pursuant to section 5165.10 of the Revised Code;

(ii) The product determined under division (D)(3)(a) of this section.

(c) Multiply the quotient determined under division (D)(3)(b) of this section by one hundred.

(4) For a nursing facility to be exempt from division (D)(1) of this section on account of division (D)(2)(c) of this section, the nursing facility's operator must provide to the department written documentation of the number of days during calendar year 2019 that one or more of the beds that are part of the nursing facility's licensed capacity could not be used and the specific reason why they could not be used.

(5) For a nursing facility to be exempt from division (D)(1) of this section on account of division (D)(2)(d) of this section, the nursing facility's operator must provide to the department written documentation that confirms the renovation and capital expenditures.

(E) A nursing facility shall not receive a quality incentive payment for state fiscal year 2021 if either of the following apply:

(1) The nursing facility's initial total per medicaid day payment rate for calendar year 2019 or state fiscal year 2021 is determined pursuant to section 5165.151 of the Revised Code.

(2) The nursing facility undergoes a change of operator during calendar year 2019 or state fiscal year 2021.

(F) The total amount to be spent on quality incentive payments for state fiscal year 2021 shall be determined as follows:

(1) 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:

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

(b) Multiply the amount determined under division (F)(1)(a) of this section by the number of the nursing facility's medicaid days for calendar year 2019.

(2) Determine the sum of the products determined under division (F)(1)(b) of this section for all nursing facilities for which the product was determined for the state fiscal year.

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