5160-3-43.3. Nursing facilities (NFs): calculation of case mix scores

(A) The definitions of all terms used in this rule are the same as set forth in rules 5160-3-01, 5160-3-43.1, and 5160-3- 43.4 of the Administrative Code.

(B) To determine resident case mix scores, the Ohio department of medicaid (ODM) shall process resident assessment data submitted by NFs in accordance with rule 5160-3-43.1 of the Administrative Code, and shall classify residents in accordance with rule 5160-3-43.2 of the Administrative Code. These resident case mix scores, based on relative resource weights calculated in accordance with rule 5160-3-43.2 of the Administrative Code, are used to establish two quarterly facility average case mix scores each quarter.

(1) The first quarterly facility average case mix score shall be calculated using all records selected for the quarter and shall be the quarterly facility average total case mix score.

(2) The second quarterly facility average case mix score shall be calculated using only the records selected for the quarter that ODM identifies as medicaid records and shall be the quarterly facility average medicaid case mix score.

(C) ODM shall calculate a quarterly facility average total case mix score for all providers meeting the following requirements:

(1) In accordance with rule 5160-3-43.1 of the Administrative Code, the provider submitted resident assessment information by the filing date, and the data included resident assessments for all residents in medicaid certified beds as of the reporting period end date, and

(a) The provider's resident assessment data submitted timely for that reporting quarter provided sufficient information for accurately classifying at least ninety per cent of all residents in medicaid certified beds into RUG non-default groups, or

(b) The provider's resident assessment data submitted timely and corrected timely, in accordance with the procedures outlined in rule 5160-3-43.1 of the Administrative Code for correcting incomplete or inaccurate information, for that reporting quarter, provided sufficient information for accurately classifying at least ninety per cent of all residents in medicaid certified beds into RUG non-default groups; and

(c) There were no errors that prevented ODM from verifying the records to be used in determining the quarterly facility average total case mix score.

(d) The prospective payment system (PPS) other medicare required assessments (OMRAs) may not be selected for calculating case mix scores.

(2) The quarterly facility average total case mix score for providers that submitted their minimum data set version 3.0 (MDS 3.0 ) data in compliance with paragraph (C)(1) of this rule shall be calculated as follows:

(a) All resident case mix scores for the quarter, including resident case mix scores in the RUG default group, are added together; then

(b) The sum of resident case mix scores is divided by the total number of residents.

(3) If a provider does not comply with paragraph (C)(1) of this rule, ODM may assign the NF a penalty score. If assigned, the penalty score for the quarterly facility average total case mix score shall be a score that is five per cent less than the quarterly facility average total case mix score for the preceding calendar quarter.

(a) If the facility was subject to an exception review for the preceding quarter in accordance with rule 5160-3-43.4 of the Administrative Code, the assigned quarterly facility average total case mix score shall be the score that is five per cent less than the score determined by the exception review.

(b) If the facility was assigned a quarterly facility average total case mix score for the preceding calendar quarter, the assigned quarterly facility average total case mix score shall be the score that is five per cent less than the score assigned for the preceding quarter.

(D) ODM shall calculate a quarterly facility average medicaid case mix score for all providers meeting the following requirements:

(1) The provider's resident assessment data submitted timely for that reporting quarter provided sufficient information for classifying at least ninety per cent of records identified as medicaid records into RUG non-default groups, or

(a) The provider's resident assessment data submitted timely and corrected timely in accordance with the procedure outlined in rule 5160-3-43.1 of the Administrative Code for correcting incomplete or inaccurate information for that reporting quarter, provided sufficient information for accurately classifying at least ninety per cent of all residents into RUG non-default groups; and

(b) There were no errors that prevented ODM from verifying the records to be used in determining the quarterly facility average medicaid case mix score.

(2) ODM shall identify a MDS 3.0 assessment as a medicaid record if the MDS 3.0 assessment meets the following requirements:

(a) The MDS 3.0 assessment is not completed to meet the requirements for a medicare part A stay.

(b) The social security number (SSN) on the MDS 3.0 assessment matches a SSN on the medicaid recipient master file (RMF)

(c) The assessment reference date (ARD) on the MDS 3.0 assessment falls within the recipient's medicaid eligibility span.

(3) The quarterly facility average medicaid case mix score for providers that submitted their MDS 3.0 data in compliance with paragraph (C)(1) of this rule shall be calculated as follows:

(a) Medicaid resident case mix scores for the quarter, including resident case mix scores in the RUG default group, are added together; then

(b) The sum of medicaid resident case mix scores is divided by the total number of medicaid residents.

(4) If a provider does not comply with paragraph (D)(1) of this rule, ODM

may assign the NF a penalty score. If assigned, the penalty score for the quarterly facility average medicaid case mix score shall be a score that is five per cent less than the quarterly facility average medicaid case mix score for the preceding calendar quarter.

(a) If the facility was subject to an exception review for the preceding quarter in accordance with rule 5160-3-43.4 of the Administrative Code, the assigned quarterly facility average medicaid case mix score shall be the score that is five per cent less than the score determined by the exception review.

(b) If the facility was assigned a quarterly facility average medicaid case mix score for the preceding calendar quarter, the assigned quarterly facility average medicaid case mix score shall be the score that is five per cent less than the score assigned for the preceding quarter.

(5) ODM may use a facility's assigned penalty score to calculate the semiannual facility average medicaid case mix score.

(E) ODM shall calculate the semiannual facility average medicaid case mix score as follows:

(1) The semiannual facility average medicaid case mix score for the payment period beginning the first day of July for a given fiscal year shall be the average of the quarterly facility average medicaid case mix score from the preceding December and March reporting quarters. If a facility does not have a quarterly facility average medicaid case mix score for both the December and March reporting quarters, the median annual facility average case mix score for the NF's peer group shall be assigned as the semiannual facility average medicaid case mix score to determine the direct care rate.

(2) The semiannual facility average medicaid case mix score for the payment period beginning the first day of January for a given fiscal year shall be the average of the quarterly facility average medicaid case mix score from the preceding June and September reporting quarters. If a facility does not have a quarterly facility average medicaid case mix score for both the June and September reporting quarters, the median annual facility average case mix score for the NF's peer group shall be assigned as the semiannual facility average medicaid case mix score to determine the direct care rate.

(F) ODM shall calculate the annual facility average case mix score as follows:

(1) The annual facility average case mix score shall be calculated only for facilities with at least two quarterly facility average total case mix scores meeting the requirements of paragraphs (C)(1) and (C)(2) of this rule. In addition, for any score meeting the requirements of paragraphs (C)(1) and (C)(2) that was adjusted, the adjusted score will be substituted according to the following hierarchy:

(a) Adjusted quarterly facility average total case mix scores established by a rate reconsideration decision resulting from an exception review of resident assessment information conducted before the effective date of the rate; or

(b) Adjusted quarterly facility average total case mix scores as a result of exception review findings.

(2) If ODM assigned a facility a quarterly facility average total case mix score in accordance with paragraph (C)(3) of this rule, the assigned score will not be used to calculate the provider's annual facility average case mix score.

(3) The qualifying case mix scores shall be summed and divided by the total number of quarters of qualifying scores to arrive at the annual facility average case mix score.

(G) For each provider that submits MDS 3.0 data in a given week, ODM shall send the "Case Mix Report" containing the following four components:

(1) The "Provider Detail Listing of Successfully Grouped Records," which identifies records that were successfully grouped by ODM. The report will include all records received, even if the records will not be used in the quarterly score calculation.

(2) The "Critical Error Summary," which identifies the records that will be assigned into the default group unless they are corrected before the end of the reporting quarter in accordance with rule 5160-3-43.1 of the Administrative Code.

(3) The "Provider Detail Listing of Records with Critical Errors," which provides detail for each record listed on the "Critical Error Summary" identifying the failed edits.

(4) The "Discharge and Reentry Tracking Form Summary," which identifies all discharge assessments and reentry tracking forms that were received by ODM.

(H) ODM shall provide two preliminary "Calculation of Facility Case Mix Scores" reports. The first report will reflect records submitted up to the quarterly filing date. The second report will reflect records submitted up to approximately two weeks prior to the quarterly corrections deadline. Both reports will include a calculation of the quarterly facility average total case mix score and the quarterly facility average medicaid case mix score. Providers may file corrections to the extent permitted by rule 5160-3-43.1 of the Administrative Code.

(I) After the quarterly corrections deadline specified in rule 5160-3-43.1 of the Administrative Code, ODM shall provide a final "Calculation of Facility Case Mix Scores" report. The report will include a calculation of the quarterly facility average total case mix score and the quarterly facility average medicaid case mix score.

(J) Following the determination of the two quarterly facility average medicaid case mix scores used to calculate the semiannual facility average medicaid case mix scores effective July first and January first of the fiscal year, ODM shall provide a "Semiannual Medicaid Case Mix Score Calculation Report" to each provider.

(K) Following the calculation of the annual facility average case mix score, ODM shall provide an "Annual Facility Average Case Mix Score Calculation Report" to each provider.

Effective: 12/31/2020
Five Year Review (FYR) Dates: 3/1/2021
Promulgated Under: 119.03
Statutory Authority: 5165.02, 5165.192
Rule Amplifies: 5165.19 , 5165.192
Prior Effective Dates: 04/15/1993 (Emer.), 07/01/1993, 07/01/1994 (Emer.), 09/30/1994, 04/20/1995, 07/01/1998, 01/01/2003, 07/01/2005, 02/13/2006, 07/01/2006, 10/01/2010, 03/01/2016