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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-3. Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities |
5160-3-65. Nursing facilities (NFs): rates for providers with an initial date of certification on or after July 1, 2006
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(A) In accordance with section 5165.151 of the Revised Code, the Ohio department of medicaid (ODM) shall determine the initial rate for the fiscal year in which the NF begins participation in the medicaid program for a NF with a first date of licensure and subsequent certification on or after July 1, 2006, including a NF that replaces one or more existing facilities, or a NF with a first date of licensure before July 1, 2006 that was initially certified for the medicaid program on or after July 1, 2006 under section 5165.151 of the Revised Code.
(1) If the number of beds in the replacement facility is greater than the number of beds in the replaced facility, the case mix score shall be equal to the weighted average of the semiannual case mix score used for the replaced beds on the last day of service at the replaced facility and the median annual average case mix score for the NF's peer group for the additional beds.
(2) If a rate for direct care costs is determined under section 5165.151 of the Revised Code for a NF using the median annual average case mix score for the NF's peer group, the rate shall be redetermined to reflect the NF's actual semiannual case mix score determined under section 5165.192 of the Revised Code after the NF submits its first two quarterly assessment data that qualify for use under paragraph (E) of rule 5160-3-43.3 of the Administrative Code. If the NF's quarterly submissions do not qualify for use in calculating a case mix score, ODM shall continue to use the median annual average case mix score for the NF's peer group in lieu of the NF's semiannual case mix score until the NF submits two consecutive quarterly assessment data that qualify for use in calculating a case mix score.
(B) After the end of the fiscal year in which the NF began participation in the medicaid program, the rates for the second fiscal year and subsequent fiscal years shall be set in accordance with section 5165.15 of the Revised Code.