Ohio Code 5165.16 – Per medicaid day payment rate for ancillary and support costs; peer groups
(A) The department of medicaid shall determine each nursing facility’s per medicaid day payment rate for ancillary and support costs. A nursing facility’s rate shall be the rate determined under division (C) of this section for the nursing facility’s peer group.
Terms Used In Ohio Code 5165.16
- 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
- Applicable calendar year: means the calendar year immediately preceding the first of the state fiscal years for which a rebasing is conducted. See Ohio Code 5165.01
- Desk-reviewed: means that a nursing facility's costs as reported on a cost report submitted 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
- 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
- Per diem: means a nursing facility's actual, allowable costs in a given cost center in a cost reporting period, divided by the nursing facility's inpatient days for that cost reporting period. See Ohio Code 5165.01
- Provider: means an operator with a provider agreement. See Ohio Code 5165.01
- Rebasing: means a redetermination of each of the following using information from cost reports for an applicable calendar year that is later than the applicable calendar year used for the previous rebasing:
(1) Each peer group's rate for ancillary and support costs as determined pursuant to division (C) of section 5165. See Ohio Code 5165.01
(B) For the purpose of determining nursing facilities’ rates for ancillary and support costs, the department shall establish six peer groups composed as follows:
(1) Each nursing facility located in any of the following counties shall be placed in peer group one or two: Brown, Butler, Clermont, Clinton, Hamilton, and Warren. Each nursing facility located in any of those counties that has fewer than one hundred beds shall be placed in peer group one. Each nursing facility located in any of those counties that has one hundred or more beds shall be placed in peer group two.
(2) Each nursing facility located in any of the following counties shall be placed in peer group three or four: Allen, Ashtabula, Champaign, Clark, Cuyahoga, Darke, Delaware, Fairfield, Fayette, Franklin, Fulton, Geauga, Greene, Hancock, Knox, Lake, Licking, Lorain, Lucas, Madison, Mahoning, Marion, Medina, Miami, Montgomery, Morrow, Ottawa, Pickaway, Portage, Preble, Ross, Sandusky, Seneca, Stark, Summit, Trumbull, Union, and Wood. Each nursing facility located in any of those counties that has fewer than one hundred beds shall be placed in peer group three. Each nursing facility located in any of those counties that has one hundred or more beds shall be placed in peer group four.
(3) Each nursing facility located in any of the following counties shall be placed in peer group five or six: Adams, Ashland, Athens, Auglaize, Belmont, Carroll, Columbiana, Coshocton, Crawford, Defiance, Erie, Gallia, Guernsey, Hardin, Harrison, Henry, Highland, Hocking, Holmes, Huron, Jackson, Jefferson, Lawrence, Logan, Meigs, Mercer, Monroe, Morgan, Muskingum, Noble, Paulding, Perry, Pike, Putnam, Richland, Scioto, Shelby, Tuscarawas, Van Wert, Vinton, Washington, Wayne, Williams, and Wyandot. Each nursing facility located in any of those counties that has fewer than one hundred beds shall be placed in peer group five. Each nursing facility located in any of those counties that has one hundred or more beds shall be placed in peer group six.
(C)(1) The department shall determine the rate for ancillary and support costs for each peer group established under division (B) of this section. The rate for ancillary and support costs determined under this division for a peer group shall be used for subsequent years until the department conducts a rebasing. To determine a peer group’s rate for ancillary and support costs, the department shall do both of the following:
(a) Determine the rate for ancillary and support costs for each nursing facility in the peer group for the applicable calendar year by using the greater of the nursing facility’s actual inpatient days for the applicable calendar year or the inpatient days the nursing facility would have had for the applicable calendar year if its occupancy rate had been ninety per cent;
(b) Subject to division (C)(2) of this section, identify which nursing facility in the peer group is at the twenty-fifth percentile of the rate for ancillary and support costs for the applicable calendar year determined under division (C)(1)(a) of this section.
(2) In making the identification under division (C)(1)(b) of this section, the department shall exclude both of the following:
(a) Nursing facilities that participated in the medicaid program under the same provider for less than twelve months in the applicable calendar year;
(b) Nursing facilities whose ancillary and support costs are more than one standard deviation from the mean desk-reviewed, actual, allowable, per diem ancillary and support cost for all nursing facilities in the nursing facility’s peer group for the applicable calendar year.
(3) The department shall not redetermine a peer group’s rate for ancillary and support costs under this division based on additional information that it receives after the rate is determined. The department shall redetermine a peer group’s rate for ancillary and support costs only if the department made an error in determining the rate based on information available to the department at the time of the original determination.
Last updated October 6, 2023 at 9:09 AM