Ohio Code 5165.26 – Nursing facility’s per medicaid day quality incentive payment rate
(A) As used in this section:
Terms Used In Ohio Code 5165.26
- Change of operator: includes circumstances in which an entering operator becomes the operator of a nursing facility in the place of the exiting operator or there is a change in owner of a nursing facility. 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.
- 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
- Medicaid days: means both of the following:
(1) All days during which a resident who is a medicaid recipient eligible for nursing facility services occupies a bed in a nursing facility that is included in the nursing facility's medicaid-certified capacity;
(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
- Operator: means the person or government entity responsible for the daily operating and management decisions for a nursing facility. 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
- Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
- state: means the state of Ohio. See Ohio Code 1.59
- State fiscal year: means the fiscal year of this state, as specified in section 9. See Ohio Code 5165.01
- United States: includes all the states. See Ohio Code 1.59
(1) “Base rate” means the portion of a nursing facility’s total per medicaid day payment rate determined under divisions (A) and (B) of section 5165.15 of the Revised Code.
(2) “CMS” means the United States centers for medicare and medicaid services.
(3) “Long-stay resident” means an individual who has resided in a nursing facility for at least one hundred one days.
(4) “Nursing facilities for which a quality score was determined” includes nursing facilities that are determined to have a quality score of zero.
(5) “SFF list” means the list of nursing facilities that the United States department of health and human services creates under the special focus facility program.
(6) “Special focus facility program” means the program conducted by the United States secretary of health and human services pursuant to section 1919(f)(10) of the “Social Security Act,” 42 U.S.C. § 1396r(f)(10).
(B) Subject to divisions (D) and (E) and except as provided in division (F) of this section, the department of medicaid shall determine each nursing facility’s per medicaid day quality incentive payment rate as follows:
(1) Determine the sum of the quality scores determined under division (C) of this section for all nursing facilities.
(2) Determine the average quality score by dividing the sum determined under division (B)(1) of this section by the number of nursing facilities for which a quality score was determined.
(3) Determine the sum of the total number of medicaid days for all of the calendar year preceding the fiscal year for which the rate is determined for all nursing facilities for which a quality score was determined.
(4) Multiply the average quality score determined under division (B)(2) of this section by the sum determined under division (B)(3) of this section.
(5) Determine the value per quality point by determining the quotient of the following:
(a) The sum determined under division (E)(2) of this section.
(b) The product determined under division (B)(4) of this section.
(6) Multiply the value per quality point determined under division (B)(5) of this section by the nursing facility’s quality score determined under division (C) of this section.
(C)(1) Except as provided in divisions (C)(2) and (3) of this section, a nursing facility’s quality score for a state fiscal year shall be the sum of the following:
(a) The total number of points that CMS assigned to the nursing facility under CMS’s nursing facility five-star quality rating system for the following quality metrics, or CMS’s successor metrics as described below, based on the most recent four-quarter average data, or the average data for fewer quarters in the case of successor metrics, available in the database maintained by CMS and known as nursing home compare in the most recent month of the calendar year during which the fiscal year for which the rate is determined begins:
(i) The percentage of the nursing facility’s long-stay residents at high risk for pressure ulcers who had pressure ulcers;
(ii) The percentage of the nursing facility’s long-stay residents who had a urinary tract infection;
(iii) The percentage of the nursing facility’s long-stay residents whose ability to move independently worsened;
(iv) The percentage of the nursing facility’s long-stay residents who had a catheter inserted and left in their bladder.
If CMS ceases to publish any of the metrics specified in division (C)(1)(a) of this section, the department shall use the nursing facility quality metrics on the same topics that CMS subsequently publishes.
(b) Seven and five-tenths points for fiscal year 2024 and three points for fiscal year 2025 and subsequent fiscal years if the nursing facility’s occupancy rate is greater than seventy-five per cent. For purposes of this division, the department shall utilize the facility’s occupancy rate for licensed beds reported on its cost report for the calendar year preceding the fiscal year for which the rate is determined or, if the facility is not required to be licensed, the facility’s occupancy rate for certified beds. If the facility surrenders licensed or certified beds before the first day of July of the calendar year in which the fiscal year begins, the department shall calculate a nursing facility’s occupancy rate by dividing the inpatient days reported on the facility’s cost report for the calendar year preceding the fiscal year for which the rate is determined by the product of the number of days in the calendar year and the facility’s number of licensed, or if applicable, certified beds on the first day of July of the calendar year in which the fiscal year begins.
(c) Beginning with state fiscal year 2025, the total number of points that CMS assigned to the nursing facility under CMS’s nursing facility five-star quality rating system for the following quality metrics, or successor metrics designated by CMS, based on the most recent four-quarter average data available in the database maintained by CMS and known as nursing home compare in the most recent month of the calendar year during which the fiscal year for which the rate is determined begins:
(i) The percentage of the nursing facility’s long-stay residents whose need for help with daily activities has increased;
(ii) The percentage of the nursing facility’s long-stay residents experiencing one or more falls with major injury;
(iii) The percentage of the nursing facility’s long-stay residents who were administered an antipsychotic medication;
(iv) Adjusted total nurse staffing hours per resident per day using quintiles instead of deciles by using the points assigned to the higher of the two deciles that constitute the quintile.
If CMS ceases to publish any of the metrics specified in division (C)(1)(c) of this section, the department shall use the nursing facility quality metrics on the same topics CMS subsequently publishes.
(2) In determining a nursing facility’s quality score for a state fiscal year, the department shall make the following adjustment to the number of points that CMS assigned to the nursing facility for each of the quality metrics specified in divisions (C)(1)(a) and (c) of this section:
(a) Unless division (C)(2)(b) or (c) of this section applies, divide the number of the nursing facility’s points for the quality metric by twenty.
(b) If CMS assigned the nursing facility to the lowest percentile for the quality metric, reduce the number of the nursing facility’s points for the quality metric to zero.
(c) If the nursing facility’s total number of points calculated for or during a state fiscal year for all of the quality metrics specified in divisions (C)(1)(a), and if applicable, division (C)(1)(c) of this section is less than a number of points that is equal to the twenty-fifth percentile of all nursing facilities, calculated using the points for the July 1 rate setting of that fiscal year reduce the nursing facility’s points to zero until the next point calculation. If a facility’s recalculated points under division (C)(3) of this section are below the number of points determined to be the twenty-fifth percentile for that fiscal year, the facility shall receive zero points for the remainder of that fiscal year.
(3) A nursing facility’s quality score shall be recalculated for the second half of the state fiscal year based on the most recent four quarter average data, or the average data for fewer quarters in the case of successor metrics, available in the database maintained by CMS and known as the care compare, in the most recent month of the calendar year during which the fiscal year for which the rate is determined begins. The metrics specified by division (C)(1)(b) of this section shall not be recalculated. In redetermining the quality payment for each facility based on the recalculated points, the department shall use the same per point value determined for the quality payment at the start of the fiscal year.
(D) A nursing facility shall not receive a quality incentive payment if the Department of Health assigned the nursing facility to the SFF list under the special focus facility program and the nursing facility is listed in table A, on the first day of May of the calendar year for which the rate is being determined.
(E) The total amount to be spent on quality incentive payments under division (B) of this section for a fiscal year shall be determined as follows:
(1) Determine the following amount for each nursing facility:
(a) The amount that is five and two-tenths per cent of the nursing facility’s base rate for nursing facility services provided on the first day of the state fiscal year plus one dollar and seventy-nine cents plus sixty per cent of the per diem amount by which the nursing facility’s rate for direct care costs determined for the fiscal year under section 5165.19 of the Revised Code changed as a result of the rebasing conducted under section 5165.36 of the Revised Code.
(b) Multiply the amount determined under division (E)(1)(a) of this section by the number of the nursing facility’s medicaid days for the calendar year preceding the fiscal year for which the rate is determined.
(2) Determine the sum of the products determined under division (E)(1)(b) of this section for all nursing facilities for which the product was determined for the state fiscal year.
(3) To the sum determined under division (E)(2) of this section, add one hundred twenty-five million dollars.
(F)(1) Beginning July 1, 2023, a new nursing facility shall receive a quality incentive payment for the fiscal year in which the new facility obtains an initial provider agreement and the immediately following fiscal year equal to the median quality incentive payment determined for nursing facilities for the fiscal year. For the state fiscal year after the immediately following fiscal year and subsequent fiscal years, the quality incentive payment shall be determined under division (C) of this section.
(2) A nursing facility that undergoes a change of operator with an effective date of July 1, 2023, or later shall not receive a quality incentive payment until the earlier of the first day of January or the first day of July that is at least six months after the effective date of the change of operator. Thereafter quality incentive payment shall be determined under division (C) of this section.
Last updated October 6, 2023 at 9:30 AM