Ohio Code 5165.192 – Case-mix scores for nursing facilities
(A)(1) Except as provided in division (B) of this section and in accordance with the process specified in rules authorized by this section, the department of medicaid shall do all of the following:
Terms Used In Ohio Code 5165.192
- Another: when used to designate the owner of property which is the subject of an offense, includes not only natural persons but also every other owner of property. See Ohio Code 1.02
- 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
- Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
- Low case-mix resident: means a medicaid recipient residing in a nursing facility who, for purposes of calculating the nursing facility's medicaid payment rate for direct care costs, is placed in either of the two lowest case-mix groups, excluding any case-mix group that is a default group used for residents with incomplete assessment data. See Ohio Code 5165.01
- Provider: means an operator with a provider agreement. See Ohio Code 5165.01
- Reasonable: means that a cost is an actual cost that is appropriate and helpful to develop and maintain the operation of patient care facilities and activities, including normal standby costs, and that does not exceed what a prudent buyer pays for a given item or services. See Ohio Code 5165.01
- state: means the state of Ohio. See Ohio Code 1.59
- Title XIX: means Title XIX of the "Social Security Act" 42 U. See Ohio Code 5165.01
- Title XVIII: means Title XVIII of the "Social Security Act" 42 U. See Ohio Code 5165.01
- United States: includes all the states. See Ohio Code 1.59
(a) Every quarter, determine the following two case-mix scores for each nursing facility:
(i) A quarterly case-mix score that includes each resident who is a medicaid recipient and is not a low case-mix resident;
(ii) A quarterly case-mix score that includes each resident regardless of payment source.
(b) Every six months, determine a semiannual average case-mix score for each nursing facility by using the quarterly case-mix scores determined for the nursing facility pursuant to division (A)(1)(a)(i) of this section;
(c) After the end of each calendar year, determine an annual average case-mix score for each nursing facility by using the quarterly case-mix scores determined for the nursing facility pursuant to division (A)(1)(a)(ii) of this section.
(2) When determining case-mix scores under division (A)(1) of this section, the department shall use all of the following:
(a) Data from a resident assessment instrument specified in rules authorized by section 5165.191 of the Revised Code;
(b) Except as provided in rules authorized by this section, the case-mix values established by the United States department of health and human services;
(c) Except as modified in rules authorized by this section, the grouper methodology used on June 30, 1999, by the United States department of health and human services for prospective payment of skilled nursing facilities under the medicare program.
(B)(1) Subject to division (B)(2) of this section, the department, for one or more months of a calendar quarter, may assign to a nursing facility a case-mix score that is five per cent less than the nursing facility’s case-mix score for the immediately preceding calendar quarter if any of the following apply:
(a) The provider does not timely submit complete and accurate resident assessment data necessary to determine the nursing facility’s case-mix score for the calendar quarter;
(b) The nursing facility was subject to an exception review under section 5165.193 of the Revised Code for the immediately preceding calendar quarter;
(c) The nursing facility was assigned a case-mix score for the immediately preceding calendar quarter.
(2) Before assigning a case-mix score to a nursing facility due to the submission of incorrect resident assessment data, the department shall permit the provider to correct the data. The department may assign the case-mix score if the provider fails to submit the corrected resident assessment data not later than the earlier of the forty-fifth day after the end of the calendar quarter to which the data pertains or the deadline for submission of such corrections established by regulations adopted by the United States department of health and human services under Title XVIII and Title XIX.
(3) If, for more than six months in a calendar year, a provider is paid a rate determined for a nursing facility using a case-mix score assigned to the nursing facility under division (B)(1) of this section, the department may assign the nursing facility a cost per case-mix unit that is five per cent less than the nursing facility’s actual or assigned cost per case-mix unit for the immediately preceding calendar year. The department may use the assigned cost per case-mix unit, instead of determining the nursing facility’s actual cost per case-mix unit in accordance with section 5165.19 of the Revised Code, to establish the nursing facility’s rate for direct care costs for the fiscal year immediately following the calendar year for which the cost per case-mix unit is assigned.
(4) The department shall take action under division (B)(1), (2), or (3) of this section only in accordance with rules authorized by this section. The department shall not take an action that affects rates for prior payment periods except in accordance with sections 5165.41 and 5165.42 of the Revised Code.
(C) The medicaid director shall adopt rules under section 5165.02 of the Revised Code as necessary to implement this section.
(1) The rules shall do all of the following:
(a) Specify the process for determining the semiannual and annual average case-mix scores for nursing facilities;
(b) Adjust the case-mix values specified in division (A)(2)(b) of this section to reflect changes in relative wage differentials that are specific to this state;
(c) Express all of those case-mix values in numeric terms that are different from the terms specified by the United States department of health and human services but that do not alter the relationship of the case-mix values to one another;
(d) Modify the grouper methodology specified in division (A)(2)(c) of this section as follows:
(i) Establish a different hierarchy for assigning residents to case-mix categories under the methodology;
(ii) Allow the use of the index maximizer element of the methodology;
(iii) Incorporate changes to the methodology the United States department of health and human services makes after June 30, 1999;
(iv) Make other changes the department determines are necessary.
(e) Establish procedures under which resident assessment data shall be reviewed for accuracy and providers shall be notified of any data that requires correction;
(f) Establish procedures for providers to correct resident assessment data and specify a reasonable period of time by which providers shall submit the corrections. The procedures may limit the content of corrections in the manner required by regulations adopted by the United States department of health and human services under Title XVIII and Title XIX.
(g) Specify when and how the department will assign case-mix scores or costs per case-mix unit to a nursing facility under division (B) of this section if information necessary to calculate the nursing facility’s case-mix score is not provided or corrected in accordance with the procedures established by the rules.
(2) Notwithstanding any other provision of this chapter, the rules may provide for the exclusion of case-mix scores assigned to a nursing facility under division (B) of this section from the determination of the nursing facility’s semiannual or annual average case-mix score and the cost per case-mix unit for the nursing facility’s peer group.
Last updated October 6, 2023 at 9:14 AM