Ohio Code 5165.151 – Initial rates for new nursing facilities
(A) The total per medicaid day payment rate determined under section 5165.15 of the Revised Code shall not be the initial rate for nursing facility services provided by a new nursing facility. Instead, the initial total per medicaid day payment rate for nursing facility services provided by a new nursing facility shall be determined in the following manner:
Terms Used In Ohio Code 5165.151
- Ancillary and support costs: includes , but is not limited to, costs of activities, social services, pharmacy consultants, habilitation supervisors, qualified intellectual disability professionals, program directors, medical and habilitation records, program supplies, incontinence supplies, food, enterals, dietary supplies and personnel, laundry, housekeeping, security, administration, medical equipment, utilities, liability insurance, bookkeeping, purchasing department, human resources, communications, travel, dues, license fees, subscriptions, home office costs not otherwise allocated, legal services, accounting services, minor equipment, maintenance and repairs, help-wanted advertising, informational advertising, start-up costs, organizational expenses, other interest, property insurance, employee training and staff development, employee benefits, payroll taxes, and workers' compensation premiums or costs for self-insurance claims and related costs as specified in rules adopted under section 5165. See Ohio Code 5165.01
- Capital costs: means the actual expense incurred by a nursing facility for all of the following:
(a) Depreciation and interest on any capital assets that cost five hundred dollars or more per item, including the following:
(i) Buildings;
(ii) Building improvements;
(iii) Except as provided in division (D) of this section, equipment;
(iv) Transportation equipment. See Ohio Code 5165.01
- Case-mix score: means a measure determined under section 5165. See Ohio Code 5165.01
- Direct care costs: means all of the following costs incurred by a nursing facility:
(1) Costs for registered nurses, licensed practical nurses, and nurse aides employed by the nursing facility;
(2) Costs for direct care staff, administrative nursing staff, medical directors, respiratory therapists, and except as provided in division (O)(8) of this section, other persons holding degrees qualifying them to provide therapy;
(3) Costs of purchased nursing services;
(4) Costs of quality assurance;
(5) Costs of training and staff development, employee benefits, payroll taxes, and workers' compensation premiums or costs for self-insurance claims and related costs as specified in rules adopted under section 5165. See Ohio Code 5165.01
- Inpatient days: means both of the following:
(1) All days during which a resident, regardless of payment source, occupies a licensed bed in a nursing facility;
(2) Fifty per cent of the days for which payment is made under section 5165. See Ohio Code 5165.01
- New nursing facility: means a nursing facility for which the provider obtains an initial provider agreement following medicaid certification of the nursing facility by the director of health, including such a nursing facility that replaces one or more nursing facilities for which a provider previously held a provider agreement. See Ohio Code 5165.01
- Occupancy rate: means the percentage of licensed beds that, regardless of payer source, are either of the following:
(1) Reserved for use under section 5165. See Ohio Code 5165.01
- Provider: means an operator with a provider agreement. See Ohio Code 5165.01
- Provider agreement: means a provider agreement, as defined in section 5164. See Ohio Code 5165.01
- Tax costs: means the costs of taxes imposed under Chapter 5751 of the Revised Code, real estate taxes, personal property taxes, and corporate franchise taxes. See Ohio Code 5165.01
(1) The initial rate for ancillary and support costs shall be the rate for the new nursing facility’s peer group determined under division (C) of section 5165.16 of the Revised Code.
(2) The initial rate for capital costs shall be the rate for the new nursing facility’s peer group determined under division (C) of section 5165.17 of the Revised Code;
(3) The initial rate for direct care costs shall be the product of the cost per case-mix unit determined under division (C) of section 5165.19 of the Revised Code for the new nursing facility’s peer group and the new nursing facility’s case-mix score determined under division (B) of this section.
(4) The initial rate for tax costs shall be the following:
(a) If the provider of the new nursing facility submits to the department of medicaid the nursing facility’s projected tax costs for the calendar year in which the provider obtains an initial provider agreement for the new nursing facility, an amount determined by dividing those projected tax costs by the number of inpatient days the nursing facility would have for that calendar year if its occupancy rate were one hundred per cent;
(b) If division (A)(4)(a) of this section does not apply, the median rate for tax costs for the new nursing facility’s peer group in which the nursing facility is placed under division (B) of section 5165.16 of the Revised Code.
(5) The initial quality incentive payment rate for the new nursing facility shall be the amount determined under section 5165.26 of the Revised Code.
(6) Sixteen dollars and forty-four cents shall be added to the sum of the rates and payment specified in divisions (A)(1) to (5) of this section.
(B) For the purpose of division (A)(3) of this section, a new nursing facility’s case-mix score shall be the following:
(1) Unless the new nursing facility replaces an existing nursing facility that participated in the medicaid program immediately before the new nursing facility begins participating in the medicaid program, the median annual average case-mix score for the new nursing facility’s peer group.
(2) If the nursing facility replaces an existing nursing facility that participated in the medicaid program immediately before the new nursing facility begins participating in the medicaid program, the semiannual case-mix score most recently determined under section 5165.192 of the Revised Code for the replaced nursing facility as adjusted, if necessary, to reflect any difference in the number of beds in the replaced and new nursing facilities.
(C) Subject to division (D) of this section, the department of medicaid shall adjust the rates established under division (A) of this section effective the first day of July, to reflect new rate calculations for all nursing facilities under this chapter.
(D) If a rate for direct care costs is determined under this section for a new nursing facility using the median annual average case-mix score for the new nursing facility’s peer group, the rate shall be redetermined to reflect the new nursing facility’s actual semiannual average case-mix score determined under section 5165.192 of the Revised Code after the new nursing facility submits its first two quarterly assessment data that qualify for use in calculating a case-mix score in accordance with rules authorized by section 5165.192 of the Revised Code. If the new nursing facility’s quarterly submissions do not qualify for use in calculating a case-mix score, the department shall continue to use the median annual average case-mix score for the new nursing facility’s peer group in lieu of the new nursing facility’s semiannual case-mix score until the new nursing facility submits two consecutive quarterly assessment data that qualify for use in calculating a case-mix score.
Last updated October 5, 2023 at 3:27 PM