Ohio Code 5165.521 – Withholding amounts owed from medicaid payments to exiting operator
(A) Except as provided in divisions (B), (C), and (D) of this section, the department of medicaid may withhold from payment due an exiting operator under the medicaid program the total amount specified in the notice provided under division (C) of section 5165.52 of the Revised Code that the exiting operator owes or may owe to the department under the medicaid program.
Terms Used In Ohio Code 5165.521
- Affiliated operator: means an operator affiliated with either of the following:
(1) The exiting operator for whom the affiliated operator is to assume liability for the entire amount of the exiting operator's debt under the medicaid program or the portion of the debt that represents the franchise permit fee the exiting operator owes;
(2) The entering operator involved in the change of operator with the exiting operator specified in division (A)(1) of this section. See Ohio Code 5165.01
- Bond: includes an undertaking. See Ohio Code 1.02
- 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
- Entering operator: means the person or government entity that will become the operator of a nursing facility when a change of operator occurs or following an involuntary termination. See Ohio Code 5165.01
- Exiting operator: means any of the following:
(1) An operator that will cease to be the operator of a nursing facility on the effective date of a change of operator;
(2) An operator that will cease to be the operator of a nursing facility on the effective date of a facility closure;
(3) An operator of a nursing facility that is undergoing or has undergone a voluntary withdrawal of participation;
(4) An operator of a nursing facility that is undergoing or has undergone an involuntary termination. See Ohio Code 5165.01
- facility closure: means either of the following:
(a) Discontinuance of the use of the building, or part of the building, that houses the facility as a nursing facility that results in the relocation of all of the nursing facility's residents;
(b) Conversion of the building, or part of the building, that houses a nursing facility to a different use with any necessary license or other approval needed for that use being obtained and one or more of the nursing facility's residents remaining in the building, or part of the building, to receive services under the new use. See Ohio Code 5165.01
- Franchise permit fee: means the fee imposed by sections 5168. See Ohio Code 5165.01
- Involuntary termination: means the department of medicaid's termination of the operator's provider agreement for the nursing facility when the termination is not taken at the operator's request. 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
- 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
- state: means the state of Ohio. See Ohio Code 1.59
- Statute: A law passed by a legislature.
- Voluntary withdrawal of participation: means an operator's voluntary election to terminate the participation of a nursing facility in the medicaid program but to continue to provide service of the type provided by a nursing facility. See Ohio Code 5165.01
(B) In the case of a change of operator and subject to division (E) of this section, the following shall apply regarding a withholding under division (A) of this section if the exiting operator or entering operator or an affiliated operator executes a successor liability agreement meeting the requirements of division (F) of this section:
(1) If the exiting operator, entering operator, or affiliated operator assumes liability for the total, actual amount of debt the exiting operator owes the department under the medicaid program as determined under section 5165.525 of the Revised Code, the department shall not make the withholding.
(2) If the exiting operator, entering operator, or affiliated operator assumes liability for only the portion of the amount specified in division (B)(1) of this section that represents the franchise permit fee the exiting operator owes, the department shall withhold not more than the difference between the total amount specified in the notice provided under division (C) of section 5165.52 of the Revised Code and the amount for which the exiting operator, entering operator, or affiliated operator assumes liability.
(C) In the case of a voluntary withdrawal of participation or facility closure and subject to division (E) of this section, the following shall apply regarding a withholding under division (A) of this section if the exiting operator or an affiliated operator executes a successor liability agreement meeting the requirements of division (F) of this section:
(1) If the exiting operator or affiliated operator assumes liability for the total, actual amount of debt the exiting operator owes the department under the medicaid program as determined under section 5165.525 of the Revised Code, the department shall not make the withholding.
(2) If the exiting operator or affiliated operator assumes liability for only the portion of the amount specified in division (C)(1) of this section that represents the franchise permit fee the exiting operator owes, the department shall withhold not more than the difference between the total amount specified in the notice provided under division (C) of section 5165.52 of the Revised Code and the amount for which the exiting operator or affiliated operator assumes liability.
(D) In the case of an involuntary termination and subject to division (E) of this section, the following shall apply regarding a withholding under division (A) of this section if the exiting operator, the entering operator, or an affiliated operator executes a successor liability agreement meeting the requirements of division (F) of this section and the department approves the successor liability agreement:
(1) If the exiting operator, entering operator, or affiliated operator assumes liability for the total, actual amount of debt the exiting operator owes the department under the medicaid program as determined under section 5165.525 of the Revised Code, the department shall not make the withholding.
(2) If the exiting operator, entering operator, or affiliated operator assumes liability for only the portion of the amount specified in division (D)(1) of this section that represents the franchise permit fee the exiting operator owes, the department shall withhold not more than the difference between the total amount specified in the notice provided under division (C) of section 5165.52 of the Revised Code and the amount for which the exiting operator, entering operator, or affiliated operator assumes liability.
(E) For an exiting operator or affiliated operator to be eligible to enter into a successor liability agreement under division (B), (C), or (D) of this section, both of the following must apply:
(1) The exiting operator or affiliated operator must have one or more valid provider agreements, other than the provider agreement for the nursing facility that is the subject of the involuntary termination, voluntary withdrawal of participation, facility closure, or change of operator;
(2) During the twelve-month period preceding either the effective date of the involuntary termination or the month in which the department receives the notice of the voluntary withdrawal of participation or facility closure under section 5165.50 of the Revised Code or the notice of the change of operator under section 5165.51 of the Revised Code, the average monthly medicaid payment made to the exiting operator or affiliated operator pursuant to the exiting operator’s or affiliated operator’s one or more provider agreements, other than the provider agreement for the nursing facility that is the subject of the involuntary termination, voluntary withdrawal of participation, facility closure, or change of operator, must equal at least ninety per cent of the sum of the following:
(a) The average monthly medicaid payment made to the exiting operator pursuant to the exiting operator’s provider agreement for the nursing facility that is the subject of the involuntary termination, voluntary withdrawal of participation, facility closure, or change of operator;
(b) Whichever of the following apply:
(i) If the exiting operator or affiliated operator has assumed liability under one or more other successor liability agreements, the total amount for which the exiting operator or affiliated operator has assumed liability under the other successor liability agreements;
(ii) If the exiting operator or affiliated operator has not assumed liability under any other successor liability agreements, zero.
(F) A successor liability agreement executed under this section must comply with all of the following:
(1) It must provide for the operator who executes the successor liability agreement to assume liability for either of the following as specified in the agreement:
(a) The total, actual amount of debt the exiting operator owes the department under the medicaid program as determined under section 5165.525 of the Revised Code;
(b) The portion of the amount specified in division (F)(1)(a) of this section that represents the franchise permit fee the exiting operator owes.
(2) It may not require the operator who executes the successor liability agreement to furnish a surety bond.
(3) It must provide that the department, after determining under section 5165.525 of the Revised Code the actual amount of debt the exiting operator owes the department under the medicaid program, may deduct the lesser of the following from medicaid payments made to the operator who executes the successor liability agreement:
(a) The total, actual amount of debt the exiting operator owes the department under the medicaid program as determined under section 5165.525 of the Revised Code;
(b) The amount for which the operator who executes the successor liability agreement assumes liability under the agreement.
(4) It must provide that the deductions authorized by division (F)(3) of this section are to be made for a number of months, not to exceed six, agreed to by the operator who executes the successor liability agreement and the department or, if the operator who executes the successor liability agreement and department cannot agree on a number of months that is less than six, a greater number of months determined by the attorney general pursuant to a claims collection process authorized by statute of this state.
(5) It must provide that, if the attorney general determines the number of months for which the deductions authorized by division (F)(3) of this section are to be made, the operator who executes the successor liability agreement shall pay, in addition to the amount collected pursuant to the attorney general’s claims collection process, the part of the amount so collected that, if not for division (H) of this section, would be required by section 109.081 of the Revised Code to be paid into the attorney general claims fund.
(G) Execution of a successor liability agreement does not waive an exiting operator’s right to contest the amount specified in the notice the department provides the exiting operator under division (C) of section 5165.52 of the Revised Code.
(H) Notwithstanding section 109.081 of the Revised Code, the entire amount that the attorney general, whether by employees or agents of the attorney general or by special counsel appointed pursuant to section 109.08 of the Revised Code, collects under a successor liability agreement, other than the additional amount the operator who executes the agreement is required by division (F)(5) of this section to pay, shall be paid to the department of medicaid for deposit into the appropriate fund. The additional amount that the operator is required to pay shall be paid into the state treasury to the credit of the attorney general claims fund created under section 109.081 of the Revised Code.
Last updated October 6, 2023 at 10:45 AM