Effective: September 30, 2021
Latest Legislation: House Bill 110 - 134th General Assembly
(A) The department of medicaid shall determine each nursing facility's per medicaid day payment rate for ancillary and support costs. A nursing facility's rate shall be the rate determined under division (C) of this section for the nursing facility's peer group.
(B) For the purpose of determining nursing facilities' rates for ancillary and support costs, the department shall establish six peer groups composed as follows:
(1) Each nursing facility located in any of the following counties shall be placed in peer group one or two: Brown, Butler, Clermont, Clinton, Hamilton, and Warren. Each nursing facility located in any of those counties that has fewer than one hundred beds shall be placed in peer group one. Each nursing facility located in any of those counties that has one hundred or more beds shall be placed in peer group two.
(2) Each nursing facility located in any of the following counties shall be placed in peer group three or four: Allen, Ashtabula, Champaign, Clark, Cuyahoga, Darke, Delaware, Fairfield, Fayette, Franklin, Fulton, Geauga, Greene, Hancock, Knox, Lake, Licking, Lorain, Lucas, Madison, Mahoning, Marion, Medina, Miami, Montgomery, Morrow, Ottawa, Pickaway, Portage, Preble, Ross, Sandusky, Seneca, Stark, Summit, Trumbull, Union, and Wood. Each nursing facility located in any of those counties that has fewer than one hundred beds shall be placed in peer group three. Each nursing facility located in any of those counties that has one hundred or more beds shall be placed in peer group four.
(3) Each nursing facility located in any of the following counties shall be placed in peer group five or six: Adams, Ashland, Athens, Auglaize, Belmont, Carroll, Columbiana, Coshocton, Crawford, Defiance, Erie, Gallia, Guernsey, Hardin, Harrison, Henry, Highland, Hocking, Holmes, Huron, Jackson, Jefferson, Lawrence, Logan, Meigs, Mercer, Monroe, Morgan, Muskingum, Noble, Paulding, Perry, Pike, Putnam, Richland, Scioto, Shelby, Tuscarawas, Van Wert, Vinton, Washington, Wayne, Williams, and Wyandot. Each nursing facility located in any of those counties that has fewer than one hundred beds shall be placed in peer group five. Each nursing facility located in any of those counties that has one hundred or more beds shall be placed in peer group six.
(C)(1) The department shall determine the rate for ancillary and support costs for each peer group established under division (B) of this section. The rate for ancillary and support costs determined under this division for a peer group shall be used for subsequent years until the department conducts a rebasing. To determine a peer group's rate for ancillary and support costs, the department shall do all of the following:
(a) Determine the rate for ancillary and support costs for each nursing facility in the peer group for the applicable calendar year by using the greater of the nursing facility's actual inpatient days for the applicable calendar year or the inpatient days the nursing facility would have had for the applicable calendar year if its occupancy rate had been ninety per cent;
(b) Subject to division (C)(2) of this section, identify which nursing facility in the peer group is at the twenty-fifth percentile of the rate for ancillary and support costs for the applicable calendar year determined under division (C)(1)(a) of this section;
(c) Multiply the rate for ancillary and support costs determined under division (C)(1)(a) of this section for the nursing facility identified under division (C)(1)(b) of this section by the rate of inflation for the eighteen-month period beginning on the first day of July of the applicable calendar year and ending the last day of December of the calendar year immediately following the applicable calendar year using the following:
(i) Except as provided in division (C)(1)(c)(ii) of this section, the consumer price index for all items for all urban consumers for the midwest region, published by the United States bureau of labor statistics;
(ii) If the United States bureau of labor statistics ceases to publish the index specified in division (C)(1)(c)(i) of this section, the index the bureau subsequently publishes that covers urban consumers' prices for items for the region that includes this state.
(2) In making the identification under division (C)(1)(b) of this section, the department shall exclude both of the following:
(a) Nursing facilities that participated in the medicaid program under the same provider for less than twelve months in the applicable calendar year;
(b) Nursing facilities whose ancillary and support costs are more than one standard deviation from the mean desk-reviewed, actual, allowable, per diem ancillary and support cost for all nursing facilities in the nursing facility's peer group for the applicable calendar year.
(3) The department shall not redetermine a peer group's rate for ancillary and support costs under this division based on additional information that it receives after the rate is determined. The department shall redetermine a peer group's rate for ancillary and support costs only if the department made an error in determining the rate based on information available to the department at the time of the original determination.
Last updated August 12, 2021 at 3:34 PM
Structure Ohio Revised Code
Chapter 5165 | Medicaid Coverage of Nursing Facility Services
Section 5165.01 | Definitions.
Section 5165.011 | Nursing Facility References.
Section 5165.03 | Admission of Mentally Ill Person to Nursing Facility.
Section 5165.04 | Assessment to Determine Level of Care.
Section 5165.06 | Nursing Facility Eligibility.
Section 5165.07 | Provider Agreement Requirements.
Section 5165.071 | Facility Operator May Contract With More Than One Provider.
Section 5165.072 | Revalidation.
Section 5165.08 | Nursing Facilities' Provider Agreement Terms.
Section 5165.081 | Action Against Facility for Breach of Provider Agreement or Other Duties.
Section 5165.082 | Qualification of Beds.
Section 5165.10 | Annual Cost Report.
Section 5165.101 | Cost of Franchise Permit Fee Not Reimbursable Expense.
Section 5165.102 | Fines Excluded From Cost Report.
Section 5165.103 | Completion of Cost Reports.
Section 5165.104 | Form of Cost Reports; Guidelines.
Section 5165.105 | Addendum for Disputed Costs.
Section 5165.106 | Termination for Failure to File Report.
Section 5165.107 | Amendments to Cost Reports.
Section 5165.108 | Desk Review of Cost Report.
Section 5165.1010 | Nursing Facility Fines.
Section 5165.15 | Calculation of Payments to Nursing Facility Providers.
Section 5165.151 | Initial Rates for New Nursing Facilities.
Section 5165.152 | Payments for Services Provided to Low Resource Utilization Residents.
Section 5165.153 | Rates for Outlier Facilities or Units.
Section 5165.155 | Amount of Payments for Dual Eligible Individuals.
Section 5165.156 | Centers of Excellence Component.
Section 5165.157 | Alternative Purchasing Model for Nursing Facility Services.
Section 5165.16 | Per Medicaid Day Payment Rate for Ancillary and Support Costs; Peer Groups.
Section 5165.17 | Per Medicaid Day Payment Rate for Reasonable Capital Costs.
Section 5165.19 | Per Medicaid Day Payment Rate for Direct Care Costs.
Section 5165.191 | Resident Assessment Data.
Section 5165.192 | Case-Mix Scores for Nursing Facilities.
Section 5165.193 | Exception Review of Assessment Data.
Section 5165.21 | Per Medicaid Day Payment Rate for Tax Costs.
Section 5165.23 | Critical Access Incentive Payments to Qualified Facilities.
Section 5165.26 | Nursing Facility's per Medicaid Day Quality Incentive Payment Rate.
Section 5165.261 | Nursing Facility Payment Commission.
Section 5165.28 | Rate for Added, Replaced, or Renovated Beds.
Section 5165.29 | Cost of Operating Rights for Relocated Beds Not Allowable Cost.
Section 5165.30 | Related Party Costs to Pass Through.
Section 5165.32 | Reduction in Rate Not Permitted.
Section 5165.33 | No Payment for Discharge Date.
Section 5165.34 | Payments Made to Reserve Bed During Temporary Absence.
Section 5165.35 | Payments Made to Facility for Services Provided After Involuntary Termination.
Section 5165.37 | Calculating Rates and Making Payments.
Section 5165.38 | Reconsideration of Rate.
Section 5165.40 | Adjustment of Rates.
Section 5165.41 | Redetermination of Rates.
Section 5165.42 | Additional Penalties.
Section 5165.43 | Determination of Interest Rate.
Section 5165.45 | Deposits to General Revenue Fund.
Section 5165.46 | Administrative Adjudication.
Section 5165.47 | Claim for Medicaid Payment for Service Provided to Nursing Facility Resident.
Section 5165.49 | Post-Payment Reviews of Nursing Facility Medicaid Claims.
Section 5165.50 | Notice of Facility Closure or Withdrawal of Participation.
Section 5165.501 | Compliance With Social Security Act Required.
Section 5165.51 | Notice of Change of Operator.
Section 5165.511 | Agreements With Entering Operators Effective on Date of Change of Operator.
Section 5165.512 | Agreements With Entering Operators Effective on a Later Date.
Section 5165.513 | Entering Operator Duties Under Provider Agreement.
Section 5165.514 | Exiting Operator Deemed Operator Pending Change.
Section 5165.515 | Provider Agreement With Operator Not Complying With Prior Agreement.
Section 5165.516 | Medicaid Reimbursement Adjustments; Change of Operator.
Section 5165.517 | Determination of Change of Operator for Purposes of Licensure Not Controlling.
Section 5165.52 | Overpayment Amounts Determined Following Notice of Closure, Etc.
Section 5165.521 | Withholding Amounts Owed From Medicaid Payments to Exiting Operator.
Section 5165.522 | Cost Report by Exiting Operator; Waiver.
Section 5165.523 | Failure to File Cost Report; Payments Deemed Overpayments.
Section 5165.524 | Final Payment Withheld Pending Receipt of Cost Reports.
Section 5165.525 | Determination of Debt of Exiting Operator; Summary Report.
Section 5165.526 | Release of Amount Withheld Less Amounts Owed.
Section 5165.527 | Release of Amount Withheld on Postponement of Change of Operator.
Section 5165.528 | Disposition of Amounts Withheld From Payment Due an Exiting Operator.
Section 5165.53 | Adoption of Rules Regarding Change in Operators.
Section 5165.60 | Definitions for Sections 5165.60 to 5165.89.
Section 5165.61 | Adoption of Rules.
Section 5165.62 | Enforcement of Provisions.
Section 5165.63 | Contracts With State Agencies for Enforcement.
Section 5165.64 | Annual Standard Surveys.
Section 5165.65 | Exit Interview With Administrator.
Section 5165.66 | Citations for Failure to Comply With One or More Certification Requirements.
Section 5165.67 | Survey Results.
Section 5165.68 | Statement of Deficiencies.
Section 5165.69 | Plan of Correction.
Section 5165.70 | On-Site Monitoring.
Section 5165.71 | Deficiencies Not Substantially Corrected.
Section 5165.72 | Uncorrected Deficiencies Constituting Severity Level Four Findings.
Section 5165.75 | Imposing Remedies and Fines.
Section 5165.76 | Fine Collected if Termination Order Does Not Take Effect.
Section 5165.77 | Emergency Remedies.
Section 5165.771 | Special Focus Facility Program.
Section 5165.78 | Appointment of Temporary Resident Safety Assurance Manager.
Section 5165.79 | Terminating Provider Agreements.
Section 5165.80 | Transfer of Residents to Other Appropriate Care Settings.
Section 5165.81 | Qualifications of Temporary Manager of Nursing Facility.
Section 5165.82 | Residents to Whom Denial of Medicaid Payments Applies.
Section 5165.84 | Order Denying Payment When Deficiency Is Not Corrected Within Time Limits.
Section 5165.85 | Termination of Participation for Failure to Correct Deficiency Within Six Months.
Section 5165.86 | Delivery of Notices.
Section 5165.88 | Confidentiality.
Section 5165.89 | Hearing on Transfer or Discharge of Resident Who Medicaid or Medicare Beneficiary.