Ohio Code 5167.21 – Payments to skilled nursing facility
(A) As used in this section:
Terms Used In Ohio Code 5167.21
- Contract: A legal written agreement that becomes binding when signed.
- Medicaid managed care organization: means a managed care organization under contract with the department of medicaid pursuant to section 5167. See Ohio Code 5167.01
- state: means the state of Ohio. See Ohio Code 1.59
- United States: includes all the states. See Ohio Code 1.59
(1) “Covered skilled nursing facility services” has the same meaning as in the “Social Security Act,” section 1888(e)(2)(A), 42 U.S.C. 1395yy(e)(2)(A).
(2) “Current medicare fee-for-service rate” means the fee-for-service rate in effect for a covered skilled nursing facility service under medicare at the time the service is provided.
(3) “Skilled nursing facility” has the same meaning as in the “Social Security Act,” section 1819(a), 42 U.S.C. §§ 1395i-3(a).
(B) Except as provided in division (C) of this section, a medicaid managed care organization shall pay a skilled nursing facility at least the current medicare fee-for-service rate, without deduction for any coinsurance, for covered skilled nursing facility services that the skilled nursing facility provides to a dual eligible individual if the medicaid managed care organization is responsible for the payment under the terms of a contract that the medicaid managed care organization, medicaid director, and United States secretary of health and human services jointly enter into under the integrated care delivery system authorized by section 5164.91 of the Revised Code.
(C) A medicaid managed care organization is required to pay the rate specified in division (B) of this section for covered skilled nursing facility services only if all of the following apply:
(1) The United States secretary agrees to the payment rate as part of the contract that the medicaid managed care organization, medicaid director, and United States secretary jointly enter into under the integrated care delivery system;
(2) The medicaid managed care organization receives a federal capitation payment that is an actuarially sufficient amount for the costs that the medicaid managed care organization incurs in paying the rate;
(3) No state funds are used for any part of the costs that the medicaid managed care organization incurs in paying the rate;
(4) The integrated care delivery system provides for dual eligible individuals to receive the covered skilled nursing facility services as part of the system.