Effective: June 30, 2021
Latest Legislation: House Bill 110 - 134th General Assembly
(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), (B), and (C) 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" means an individual who has resided in a nursing facility for at least one hundred one days.
(5) "Nursing facilities for which a quality score was determined" includes nursing facilities that are determined to have a quality score of zero.
(6) "SFF list" means the list of nursing facilities that the United States department of health and human services creates under the special focus facility program.
(7) "Special focus facility program" means the program conducted by the United States secretary of health and human services pursuant to section 1919(f)(10) of the "Social Security Act," 42 U.S.C. 1396r(f)(10).
(B) For state fiscal year 2022 and state fiscal year 2023, and subject to divisions (D), (E), and (F), and except as provided in division (G) 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 sum of the total number of medicaid days for all of the calendar year preceding the fiscal year for which the rate is determined 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 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 division (C)(2) of this section, a nursing facility's quality score for state fiscal year 2022 and state fiscal year 2023 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 CMS and known as nursing home compare in the most recent month of the calendar year during which the fiscal year for which the rate is determined begins:
(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 2022 and state fiscal year 2023, 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) or (c) 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.
(c) If the nursing facility's total number of points for state fiscal year 2022 or for state fiscal year 2023 for all of the quality metrics specified in division (C)(1) of this section is less than a number of points that is equal to the twenty-fifth percentile of all nursing facilities, reduce the nursing facility's points to zero for that fiscal year.
(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 2022 or state fiscal year 2023 if the Department of Health assigned the nursing facility to the SFF list under the special focus facility program and the nursing facility is listed in table A, table B, or table C on the first day of May of the calendar year for which the rate is being determined.
(F) The total amount to be spent on quality incentive payments under division (B) of this section for each fiscal year during state fiscal years 2022 and 2023 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 plus one dollar and seventy-nine cents;
(b) Multiply the amount determined under division (F)(1)(a) of this section by the number of the nursing facility's medicaid days for the calendar year preceding the fiscal year for which the rate is determined.
(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.
(3) To the sum determined under division (F)(2) of this section, add twenty-five million dollars for fiscal year 2022 and one hundred twenty-five million dollars for fiscal year 2023.
(G) A new nursing facility or a nursing facility that undergoes a change of operator during fiscal year 2022 or fiscal year 2023 shall not receive a quality incentive payment for the fiscal year in which the new facility obtains an initial provider agreement or the change of operator occurred, whichever is applicable. For the immediately following state fiscal year, the quality incentive payment shall be determined under division (C) of this section.
(H) Divisions (C)(3) and (D) of this section are suspended beginning July 1, 2021, and ending June 30, 2023.
Last updated August 12, 2021 at 3:36 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.