Ohio Code 5165.19 – Per medicaid day payment rate for direct care costs
(A)(1) Semiannually, except as provided in division (A)(2) of this section, the department of medicaid shall determine each nursing facility’s per medicaid day payment rate for direct care costs by multiplying the facility’s semiannual case-mix score determined under section 5165.192 of the Revised Code by the cost per case-mix unit determined under division (C) of this section for the facility’s peer group.
Terms Used In Ohio Code 5165.19
- 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
- Case-mix score: means a measure determined under section 5165. 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
- 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
- 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
- state: means the state of Ohio. See Ohio Code 1.59
(2) Beginning January 1, 2024, during state fiscal years 2024 and 2025, the department shall determine each nursing facility’s per medicaid day payment rate for direct care costs by multiplying the cost per case-mix unit determined under division (C) of this section for the facility’s peer group by the case-mix score specified in division (A)(2)(a) or (b) of this section, as selected by the nursing facility not later than October 1, 2023. If the nursing facility does not make a selection by October 1, 2023, the case-mix score specified in division (A)(2)(a) of this section shall apply. The case-mix score may be either of the following:
(a) The semiannual case-mix score determined for the facility under division (A)(1) of this section;
(b) The facility’s quarterly case-mix score from March 31, 2023, which shall apply to the facility’s direct care rate from January 1, 2024, to June 30, 2025.
(B) For the purpose of determining nursing facilities’ rates for direct care costs, the department shall establish three peer groups.
(1) Each nursing facility located in any of the following counties shall be placed in peer group one: Brown, Butler, Clermont, Clinton, Hamilton, and Warren.
(2) Each nursing facility located in any of the following counties shall be placed in peer group two: 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.
(3) Each nursing facility located in any of the following counties shall be placed in peer group three: 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.
(C)(1) The department shall determine a cost per case-mix unit for each peer group established under division (B) of this section. The cost per case-mix unit 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 cost per case-mix unit, the department shall do both of the following:
(a) Determine the cost per case-mix unit for each nursing facility in the peer group for the applicable calendar year by dividing each facility’s desk-reviewed, actual, allowable, per diem direct care costs for the applicable calendar year by the facility’s annual average case-mix score determined under section 5165.192 of the Revised Code for the applicable calendar year;
(b) Subject to division (C)(2) of this section, identify which nursing facility in the peer group is at the seventieth percentile of the cost per case-mix units 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 cost per case-mix unit is more than one standard deviation from the mean cost per case-mix unit 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 cost per case-mix unit under this division based on additional information that it receives after the peer group’s per case-mix unit is determined. The department shall redetermine a peer group’s cost per case-mix unit only if it made an error in determining the peer group’s cost per case-mix unit based on information available to the department at the time of the original determination.
Last updated October 6, 2023 at 9:12 AM