5160-3-42.4. Nursing facilities (NFs): non-reimbursable costs

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 accordance with Chapter 119. of the Revised Code.

(C) Costs that exceed prudent buyer tests of reasonableness that may be applied pursuant to the provisions of the centers for medicare and medicaid services (CMS) publication 15-1 "Provider Reimbursement Manual" (rev. 9/28/15) during the audit of NF cost reports.

(D) Costs of ancillary services rendered to NF residents by providers who bill medicaid directly. Ancillary services include but are not limited to physicians, legend drugs, radiology, and laboratory.

(E) Costs per case-mix units in excess of the applicable peer group ceiling for direct care costs.

(F) Expenses in excess of the capital costs limitations.

(G) Expenses associated with lawsuits filed against the Ohio department of medicaid (ODM) that are not upheld by the courts.

(H) Costs of meals sold to visitors or the public ( e.g., meals on wheels).

(I) Costs of supplies or services sold to nonfacility residents or the public. (J) Costs of operating a gift shop.

Effective: 8/31/2017
Five Year Review (FYR) Dates: 6/15/2017 and 08/31/2022
Promulgated Under: 119.03
Statutory Authority: 5165.02
Rule Amplifies: 5165.02
Prior Effective Dates: 12/30/77, 8/3/79, 7/1/80, 1/1/84, 7/1/88 (Emer.), 9/25/88, 12/30/88 (Emer.), 3/31/89 (Emer.), 6/18/89, 10/1/89, 12/20/91, 9/30/93 (Emer.), 1/1/94, 12/17/98, 9/12/03, 2/9/06, 2/15/10, 3/19/12