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2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.106 | Termination for Failure to File Report.

Effective:
November 22, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
If a nursing facility provider required by section 5165.10 of the Revised Code to file a cost report for the nursing facility fails to file the cost report by the date it is due or the date, if any, to which the due date is extended pursuant to division (D) of that section, or files an incomplete or inadequate report for the nursing facility under that section, the department of medicaid shall provide immediate written notice to the provider that the provider agreement for the nursing facility will be terminated in thirty days unless the provider submits a complete and adequate cost report for the nursing facility within thirty days. During the thirty-day termination period or any additional time allowed for an appeal of the proposed termination of a provider agreement, the provider shall be paid the nursing facility's then current per medicaid day payment rate, minus the dollar amount by which nursing facility's per medicaid day payment rates are reduced during state fiscal year 2013 in accordance with division (A)(2) of section 5111.26 of the Revised Code (renumbered as section 5165.10 of the Revised Code by H.B. 59 of the 130th general assembly) as that section existed on the day immediately preceding September 29, 2013. On the first day of each July, the department shall adjust the amount of the reduction in effect during the previous twelve months to reflect the rate of inflation during the preceding twelve months, as shown in the consumer price index for all items for all urban consumers for the north central region, published by the United States bureau of labor statistics.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.107 | Amendments to Cost Reports.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) Except as provided in division (B) of this section and not later than three years after a nursing facility provider files a cost report with the department of medicaid under section 5165.10 of the Revised Code, the provider may amend the cost report if the provider discovers a material error in the cost report or additional information to be included in the cost report. The department shall review the amended cost report for accuracy and notify the provider of its determination.
(B) A provider may not amend a cost report if the department has notified the provider that an audit of the cost report or a cost report of the provider for a subsequent cost reporting period is to be conducted under section 5165.109 of the Revised Code. The provider may, however, provide the department information that affects the costs included in the cost report. Such information may not be provided after the adjudication of the final settlement of the cost report.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.108 | Desk Review of Cost Report.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) The department of medicaid shall conduct a desk review of each cost report it receives under section 5165.10 or 5165.522 of the Revised Code. Based on the desk review, the department shall make a preliminary determination of whether the reported costs are allowable costs. The department shall notify each nursing facility provider of whether any of the reported costs are preliminarily determined not to be allowable, the medicaid payment rate determined under this chapter that results from that determination, and the reasons for the determination and resulting rate. The department shall allow the provider to verify the calculation and submit additional information.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.1010 | Nursing Facility Fines.

Effective:
September 29, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
(A) Subject to division (D) of this section, the department of medicaid shall fine the provider of a nursing facility if the report of an audit conducted under section 5165.109 of the Revised Code regarding a cost report for the nursing facility includes either of the following:
(1) Adverse findings that exceed three per cent of the total amount of medicaid-allowable costs reported in the cost report;
(2) Adverse findings that exceed twenty per cent of medicaid-allowable costs for a particular cost center reported in the cost report.
(B) A fine issued under this section shall equal the greatest of the following:
(1) If the adverse findings exceed three per cent but do not exceed ten per cent of the total amount of medicaid-allowable costs reported in the cost report, the greater of three per cent of those reported costs or ten thousand dollars;
(2) If the adverse findings exceed ten per cent but do not exceed twenty per cent of the total amount of medicaid-allowable costs reported in the cost report, the greater of six per cent of those reported costs or twenty-five thousand dollars;
(3) If the adverse findings exceed twenty per cent of the total amount of medicaid-allowable costs reported in the cost report, the greater of ten per cent of those reported costs or fifty thousand dollars;
(4) If the adverse findings exceed twenty per cent but do not exceed twenty-five per cent of medicaid-allowable costs for a particular cost center reported in the cost report, the greater of three per cent of the total amount of medicaid-allowable costs reported in the cost report or ten thousand dollars;
(5) If the adverse findings exceed twenty-five per cent but do not exceed thirty per cent of medicaid-allowable costs for a particular cost center reported in the cost report, the greater of six per cent of the total amount of medicaid-allowable costs reported in the cost report or twenty-five thousand dollars;
(6) If the adverse findings exceed thirty per cent of medicaid-allowable costs for a particular cost center reported in the cost report, the greater of ten per cent of the total amount of medicaid-allowable costs reported in the cost report or fifty thousand dollars.
(C) Fines paid under this section shall be deposited into the health care/medicaid support and recoveries fund created under section 5162.52 of the Revised Code.
(D) The department may not collect a fine under this section until all appeal rights relating to the audit report that is the basis for the fine are exhausted.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.15 | Calculation of Payments to Nursing Facility Providers.

Effective:
July 4, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
Except as otherwise provided by sections 5165.151 to 5165.158 and 5165.34 of the Revised Code, the total per medicaid day payment rate that the department of medicaid shall pay a nursing facility provider for nursing facility services the provider's nursing facility provides during a state fiscal year shall be determined as follows:
(A) Determine the sum of all of the following:
(1) The per medicaid day payment rate for ancillary and support costs determined for the nursing facility under section 5165.16 of the Revised Code;
(2) The per medicaid day payment rate for capital costs determined for the nursing facility under section 5165.17 of the Revised Code;
(3) The per medicaid day payment rate for direct care costs determined for the nursing facility under section 5165.19 of the Revised Code;
(4) The per medicaid day payment rate for tax costs determined for the nursing facility under section 5165.21 of the Revised Code;
(5) If the nursing facility qualifies as a critical access nursing facility, the nursing facility's critical access incentive payment paid under section 5165.23 of the Revised Code.
(B) To the sum determined under division (A) of this section, add sixteen dollars and forty-four cents.
(C) To the sum determined under division (B) of this section, add the per medicaid day quality incentive payment rate determined for the nursing facility under section 5165.26 of the Revised Code.
(D) If the nursing facility qualifies as a low occupancy nursing facility, subtract from the sum determined under division (C) of this section the nursing facility's low occupancy deduction determined under section 5165.23 of the Revised Code.
Last updated October 5, 2023 at 3:27 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.152 | Payments for Services Provided to Low Resource Utilization Residents.

Effective:
July 4, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
The total per medicaid day payment rate determined under section 5165.15 of the Revised Code shall not be paid for nursing facility services provided to low case-mix residents. Instead, the total rate for such nursing facility services shall be one hundred fifteen dollars per medicaid day.
Last updated October 5, 2023 at 3:28 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.154 | Calculating Prospective Rates for Facilities With Residents Whose Care Costs Are Not Adequately Measured.

Effective:
November 22, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
(A) To the extent, if any, provided for in rules authorized by this section, the total per medicaid day payment rate determined under section 5165.15 of the Revised Code shall not be paid for nursing facility services that a nursing facility not designated as an outlier nursing facility or unit provides to a resident who meets the criteria for admission to a designated outlier nursing facility or unit, as specified in rules authorized by section 5165.153 of the Revised Code. Instead, the provider of a nursing facility providing nursing facility services to such a resident shall be paid each state fiscal year a total per medicaid day payment rate that the department of medicaid shall prospectively determine in accordance with a methodology established in rules authorized by this section.
(B) The medicaid director may adopt rules under section 5165.02 of the Revised Code to implement this section. The rules may require that a nursing facility receive authorization from the department before admitting or retaining a resident who meets the criteria for admission to a designated outlier nursing facility or unit. If the director adopts such rules, the rules shall specify the criteria and procedures the department will apply when granting the authorization.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.155 | Amount of Payments for Dual Eligible Individuals.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) As used in this section, "medicaid maximum allowable amount" means one hundred per cent of a nursing facility's total per medicaid day payment rate.
(B) Instead of paying the total per medicaid day payment rate determined under section 5165.15 of the Revised Code, the department of medicaid shall pay the provider of a nursing facility the lesser of the following for nursing facility services the nursing facility provides on or after January 1, 2012, to a dual eligible individual who is eligible for nursing facility services under the medicaid program and post-hospital extended care services under Part A of Title XVIII:
(1) The coinsurance amount for the services as provided under Part A of Title XVIII;
(2) The medicaid maximum allowable amount for the services, less the amount paid under Part A of Title XVIII for the services.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.156 | Centers of Excellence Component.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director may establish a centers of excellence component of the medicaid program. The purpose of the centers of excellence component is to increase the efficiency and quality of nursing facility services provided to medicaid recipients with complex nursing facility service needs. The director may adopt rules under section 5165.02 of the Revised Code governing the component, including rules that establish a method of determining the medicaid payment rates for nursing facilities providing nursing facility services to medicaid recipients participating in the component. The rules may specify the extent to which, if any, of the provisions of sections 5165.153 and 5165.154 of the Revised Code are to apply to the centers of excellence component. If such rules are adopted, the nursing facilities that provide nursing facility services to medicaid recipients participating in the centers of excellence component shall be paid for those services in accordance with the method established in the rules instead of the total per medicaid day payment rate determined under section 5165.15 of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.191 | Resident Assessment Data.

Effective:
September 30, 2021
Latest Legislation:
House Bill 110 - 134th General Assembly
Each calendar quarter, each nursing facility provider shall compile complete assessment data for each resident of each of the provider's nursing facilities, regardless of payment source, who is in the nursing facility, or on hospital or therapeutic leave from the nursing facility, on the last day of the quarter. A resident assessment instrument specified in rules authorized by this section shall be used to compile the resident assessment data. Each provider shall submit the resident assessment data to the department of health and, if required by the rules, the department of medicaid. The resident assessment data shall be submitted not later than fifteen days after the end of the calendar quarter for which the data is compiled. If the resident assessment data is to be submitted to the department of medicaid, it shall be submitted to the department through the medium or media specified in the rules.
Rules adopted under section 5165.02 of the Revised Code shall do all of the following:
(A) In a manner consistent with the "Social Security Act," section 1919(e)(5), 42 U.S.C. 1396r(e)(5), specify a resident assessment instrument to be used by nursing facility providers under this section;
(B) Specify whether nursing facility providers must submit the resident assessment data to the department of medicaid;
(C) Specify any resident assessment data that is excluded from the case mix calculation made under section 5165.192 of the Revised Code;
(D) If the rules specify that nursing facility providers must submit the resident assessment data to the department, specify the medium or media through which the data is to be submitted.
Last updated August 12, 2021 at 3:35 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.21 | Per Medicaid Day Payment Rate for Tax Costs.

Effective:
October 17, 2019
Latest Legislation:
House Bill 166 - 133rd General Assembly
The department of medicaid shall determine each nursing facility's per medicaid day payment rate for tax costs. The rate for tax costs determined under this division for a nursing facility shall be used for subsequent years until the department conducts a rebasing. To determine a nursing facility's rate for tax costs, the department shall divide the nursing facility's desk-reviewed, actual, allowable tax costs paid for the applicable calendar year by the number of inpatient days the nursing facility would have had if its occupancy rate had been one hundred per cent during the applicable calendar year.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.261 | Nursing Facility Payment Commission.

Effective:
September 30, 2021
Latest Legislation:
House Bill 110 - 134th General Assembly
(A) There is hereby established the nursing facility payment commission. The commission shall consist of the following members:
(1) Four members appointed by the speaker of the house of representatives, three from the majority party and one from the minority party;
(2) Four members appointed by the president of the senate, three from the majority party and one from the minority party.
(B) Appointments to the commission shall be made not later than December 31, 2021. In the event of a vacancy, a replacement member shall be appointed in the same manner as initial appointments. Members shall serve without compensation.
At the initial meeting, commission members shall elect one member from the majority party of the house of representatives and one member from the majority party of the senate to serve as joint co-chairpersons of the commission.
(C) The commission shall analyze the efficacy of all of the following:
(1) The current quality incentive payment formula under section 5165.26 of the Revised Code for efficacy;
(2) The nursing facility base rate calculation, as defined under section 5165.26 of the Revised Code;
(3) The nursing facility cost centers, which are redetermined as part of the rebasing process under section 5165.36 of the Revised Code;
(4) Establishing a bed buyback program under which a nursing facility operator can permanently surrender one or more long-term care beds due to a decrease in bed utilization.
(D) Not later than August 31, 2022, the commission shall submit a report to the general assembly, in accordance with section 101.68 of the Revised Code, with its recommendations and determinations on the items listed under division (C) of this section.
Last updated September 9, 2021 at 3:01 PM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.28 | Rate for Added, Replaced, or Renovated Beds.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
If a provider of a nursing facility adds or replaces one or more medicaid certified beds to or at the nursing facility, or renovates one or more of the nursing facility's beds, the medicaid payment rate for the added, replaced, or renovated beds shall be the same as the medicaid payment rate for the nursing facility's existing beds.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.29 | Cost of Operating Rights for Relocated Beds Not Allowable Cost.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
If one or more medicaid-certified beds are relocated from one nursing facility to another nursing facility owned by a different person or government entity and the application for the certificate of need authorizing the relocation is filed with the director of health on or after July 1, 2005, amortization of the cost of acquiring operating rights for the relocated beds is not an allowable cost for the purpose of determining the nursing facility's medicaid payment rate.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.30 | Related Party Costs to Pass Through.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
Except as provided in section 5165.17 of the Revised Code, the costs of goods, services, and facilities, furnished to a nursing facility provider by a related party are includable in the allowable costs of the provider at the reasonable cost to the related party.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.32 | Reduction in Rate Not Permitted.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid shall not reduce a nursing facility's medicaid payment rate determined under this chapter on the basis that the provider charges a lower rate to any resident who is not eligible for medicaid.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.33 | No Payment for Discharge Date.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
No medicaid payment shall be made to a nursing facility provider for the day a medicaid recipient is discharged from the nursing facility.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.34 | Payments Made to Reserve Bed During Temporary Absence.

Effective:
November 22, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
(A) The department of medicaid may make medicaid payments to a nursing facility provider under this chapter to reserve a bed for a recipient during a temporary absence under conditions prescribed by the department, to include hospitalization for an acute condition, visits with relatives and friends, and participation in therapeutic programs outside the facility, when the resident's plan of care provides for such absence and federal financial participation for the payments is available.
(B) The maximum period for which payments may be made to reserve a bed in a nursing facility shall not exceed thirty days in a calendar year.
(C) The department shall establish the per medicaid day payment rates for reserving beds under this section. In establishing the per medicaid day payment rates, the department shall set the per medicaid day payment rate at an amount equal to the following:
(1) In the case of a nursing facility that had an occupancy rate exceeding ninety-five per cent, an amount not exceeding fifty per cent of the per medicaid day payment rate the provider would be paid if the recipient were not absent from the nursing facility that day;
(2) In the case of a nursing facility that had an occupancy rate not exceeding ninety-five per cent, an amount not exceeding eighteen per cent of the per medicaid day payment rate the provider would be paid if the recipient were not absent from the nursing facility that day.
(D) For the purpose of setting a nursing facility's per medicaid day payment rate to reserve a bed for a day during the period beginning on September 29, 2013, and ending December 31, 2013, the department shall determine the nursing facility's occupancy rate by using information reported on the nursing facility's cost report for calendar year 2012. For the purpose of setting a nursing facility's per medicaid day payment rate to reserve a bed for January 1, 2014, or thereafter, the department shall determine the nursing facility's occupancy rate by using information reported on the nursing facility's cost report for the calendar year preceding the state fiscal year in which the reservation falls.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.35 | Payments Made to Facility for Services Provided After Involuntary Termination.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
Medicaid payments may be made for nursing facility services provided not later than thirty days after the effective date of an involuntary termination of the nursing facility that provides the services if the services are provided to a medicaid recipient who is eligible for the services and resided in the nursing facility before the effective date of the involuntary termination.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.36 | Rebasing.

Effective:
July 4, 2023
Latest Legislation:
House Bill 33 - 135th General Assembly
Beginning with state fiscal year 2024, the department of medicaid shall conduct a rebasing at least once every five state fiscal years. When the department conducts the rebasing for a state fiscal year, it shall conduct the rebasing for only the direct care and tax cost centers.
Last updated October 6, 2023 at 10:39 AM
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.37 | Calculating Rates and Making Payments.

Effective:
November 22, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
The department of medicaid shall make its best efforts each year to calculate nursing facilities' medicaid payment rates under this chapter in time to pay the rates by the fifteenth day of August of each state fiscal year. If the department is unable to calculate the rates so that they can be paid by that date, the department shall pay each provider the rate calculated for the provider's nursing facilities under this chapter at the end of the previous state fiscal year. If the department also is unable to calculate the rates to pay the rates by the fifteenth day of September and the fifteenth day of October, the department shall pay the previous state fiscal year's rate to make those payments. The department may increase by five per cent the previous state fiscal year's rate paid for any nursing facility pursuant to this section at the request of the provider. The department shall use rates calculated for the current state fiscal year to make the payments due by the fifteenth day of November.
If the rate paid to a provider for a nursing facility pursuant to this section is lower than the rate calculated for the nursing facility for the current state fiscal year, the department shall pay the provider the difference between the two rates for the number of days for which the provider was paid for the nursing facility pursuant to this section. If the rate paid for a nursing facility pursuant to this section is higher than the rate calculated for it for the current state fiscal year, the provider shall refund to the department the difference between the two rates for the number of days for which the provider was paid for the nursing facility pursuant to this section.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.38 | Reconsideration of Rate.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The medicaid director shall adopt rules under section 5165.02 of the Revised Code that establish a process under which a nursing facility provider, or a group or association of nursing facility providers, may seek reconsideration of medicaid payment rates established under this chapter, including a rate for direct care costs recalculated before the effective date of the rate as a result of an exception review of resident assessment data conducted under section 5165.193 of the Revised Code. The only issue that a provider, group, or association may raise in the rate reconsideration shall be whether the rate was calculated in accordance with this chapter and the rules adopted under section 5165.02 of the Revised Code. The provider, group, or association may submit written arguments or other materials that support its position. The provider, group, or association and department of medicaid shall take actions regarding the rate reconsideration within time frames specified in rules authorized by this section.
If the department determines, as a result of the rate reconsideration, that the rate determined for one or more nursing facilities is less than the rate to which the nursing facility is entitled, the department shall increase the rate. If the department has paid the incorrect rate for a period of time, the department shall pay the provider the difference between the amount the provider was paid for that period for the nursing facility and the amount the provider should have been paid for the nursing facility.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.40 | Adjustment of Rates.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
If a nursing facility provider properly amends a cost report for the nursing facility under section 5165.107 of the Revised Code and the amended report shows that the provider received a lower medicaid payment rate under the original cost report than the provider was entitled to receive, the department of medicaid shall adjust the provider's rate for the nursing facility prospectively to reflect the corrected information. The department shall pay the adjusted rate beginning two months after the first day of the month after the provider files the amended cost report.
If the department finds, from an exception review of resident assessment data conducted pursuant to section 5165.193 of the Revised Code after the effective date of a nursing facility's rate for direct care costs that is based on the resident assessment data, that inaccurate resident assessment data resulted in the provider receiving a lower rate for the nursing facility than it was entitled to receive, the department prospectively shall adjust the provider's rate accordingly. The department shall make payments to the provider using the adjusted rate for the remainder of the six-month period for which the resident assessment data is used to determine the rate, beginning one month after the first day of the month after the exception review is completed.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.41 | Redetermination of Rates.

Effective:
November 22, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
(A) The department of medicaid shall redetermine a provider's medicaid payment rate for a nursing facility using revised information if any of the following results in a determination that the provider received a higher medicaid payment rate for the nursing facility than the provider was entitled to receive:
(1) The provider properly amends a cost report for the nursing facility under section 5165.107 of the Revised Code;
(2) The department makes a finding based on an audit under section 5165.109 of the Revised Code;
(3) The department makes a finding based on an exception review of resident assessment data conducted under section 5165.193 of the Revised Code after the effective date of the nursing facility's rate for direct care costs that is based on the resident assessment data;
(4) The department makes a finding based on a post-payment review conducted under section 5165.49 of the Revised Code.
(B) The department shall apply the redetermined rate to the periods when the provider received the incorrect rate to determine the amount of the overpayment. The provider shall refund the amount of the overpayment. The department may charge the provider the following amount of interest from the time the overpayment was made:
(1) If the overpayment resulted from costs reported for calendar year 1993, the interest shall be no greater than one and one-half times the current average bank prime rate.
(2) If the overpayment resulted from costs reported for a subsequent calendar year:
(a) The interest shall be no greater than two times the current average bank prime rate if the overpayment was no more than one per cent of the total medicaid payments to the provider for the state fiscal year for which the overpayment was made.
(b) The interest shall be no greater than two and one-half times the current average bank prime rate if the overpayment was more than one per cent of the total medicaid payments to the provider for the state fiscal year for which the overpayment was made.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.42 | Additional Penalties.

Effective:
November 22, 2017
Latest Legislation:
House Bill 49 - 132nd General Assembly
In addition to the other penalties authorized by this chapter, the department of medicaid may impose the following penalties on a nursing facility provider:
(A) If the provider does not furnish invoices or other documentation that the department requests during an audit within sixty days after the request, a fine of no more than the greater of the following:
(1) One thousand dollars per audit;
(2) Twenty-five per cent of the cumulative amount by which the costs for which documentation was not furnished increased the total medicaid payments to the provider during the state fiscal year for which the costs were used to determine a rate.
(B) If an exiting operator or owner fails to provide notice of a facility closure or voluntary withdrawal of participation in the medicaid program as required by section 5165.50 of the Revised Code, or an exiting operator or owner and entering operator fail to provide notice of a change of operator as required by section 5165.51 of the Revised Code, a fine of not more than the current average bank prime rate plus four per cent of the last two monthly payments.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.43 | Determination of Interest Rate.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
For the purposes of sections 5165.41 and 5165.42 of the Revised Code, the department of medicaid shall determine the current average bank prime rate using statistical release H.15, "selected interest rates," a weekly publication of the federal reserve board, or any successor publication. If statistical release H.15, or its successor, ceases to contain the bank prime rate information or ceases to be published, the department shall request a written statement of the average bank prime rate from the federal reserve bank of Cleveland or the federal reserve board.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.44 | Deductions.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) Except as provided in division (B) of this section, the department of medicaid shall deduct the following from the next available medicaid payment the department makes to a nursing facility provider who continues to participate in medicaid:
(1) Any amount the provider is required to refund, and any interest charged, under section 5165.41 of the Revised Code;
(2) The amount of any penalty imposed on the provider under section 5165.42 of the Revised Code.
(B) The department and a nursing facility provider may enter into an agreement under which a deduction required by division (A) of this section is taken in installments from payments the department makes to the provider.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.45 | Deposits to General Revenue Fund.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid shall transmit to the treasurer of state for deposit in the general revenue fund amounts collected from the following:
(A) Refunds required by, and interest charged under, section 5165.41 of the Revised Code;
(B) Amounts collected from penalties imposed under section 5165.42 of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.46 | Administrative Adjudication.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
All of the following are subject to an adjudication conducted in accordance with Chapter 119. of the Revised Code:
(A) Any audit disallowance that the department of medicaid makes as the result of an audit under section 5165.109 of the Revised Code;
(B) Any adverse finding that results from an exception review of resident assessment data conducted for a nursing facility under section 5165.193 of the Revised Code after the effective date of the nursing facility's medicaid payment rate for direct care costs that is based on the resident assessment data;
(C) Any medicaid payment deemed an overpayment under section 5165.523 of the Revised Code;
(D) Any penalty the department imposes under section 5165.42 of the Revised Code or section 5165.523 of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.47 | Claim for Medicaid Payment for Service Provided to Nursing Facility Resident.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
No person, other than a nursing facility provider, shall submit a claim for medicaid payment for a service provided to a nursing facility resident if the service is included in a medicaid payment made to the nursing facility provider under this chapter or in the allowable expenses reported on a provider's cost report for a nursing facility. No nursing facility provider shall submit a separate claim for medicaid payment for a service provided to a resident of the nursing facility if the service is included in a medicaid payment made to the provider under this chapter or in the allowable expenses on the provider's cost report for the nursing facility.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.48 | Nursing Facility Not Required to Submit Medicaid Claim for Medicare Cost-Sharing Expenses Under Certain Circumstances.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The provider of a nursing facility is not required to submit a claim to the department of medicaid regarding the medicare cost-sharing expenses of a resident of the nursing facility who, under federal law, is eligible to have the medicaid program pay for a part of the cost-sharing expenses if the provider determines that, under rules adopted under section 5165.02 of the Revised Code, the nursing facility would not receive a medicaid payment for any part of the medicare cost-sharing expenses. In such a situation, a claim for the medicare cost-sharing expenses shall be considered to have been adjudicated at no payment.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.49 | Post-Payment Reviews of Nursing Facility Medicaid Claims.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid may conduct a post-payment review of a claim submitted by a nursing facility provider and paid by the medicaid program to determine whether the provider was overpaid. The department shall provide the provider a written summary of the review's results. The review's results are not subject to an adjudication under Chapter 119. of the Revised Code; however, the provider may request that the medicaid director reconsider the review's results. The director shall reconsider the review's results on receipt of a request made in good faith. The department shall not deduct any amounts the department claims to be due from the provider as a result of the review from the provider's medicaid payments pursuant to section 5165.44 of the Revised Code until the conclusion of the director's reconsideration, if any, of the review.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.50 | Notice of Facility Closure or Withdrawal of Participation.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
An exiting operator or owner of a nursing facility participating in the medicaid program shall provide the department of medicaid written notice of a facility closure or voluntary withdrawal of participation not less than ninety days before the effective date of the facility closure or voluntary withdrawal of participation. The written notice shall be provided to the department in accordance with the method specified in rules authorized by section 5165.53 of the Revised Code.
The written notice shall include all of the following:
(A) The name of the exiting operator and, if any, the exiting operator's authorized agent;
(B) The name of the nursing facility that is the subject of the written notice;
(C) The exiting operator's medicaid provider agreement number for the nursing facility that is the subject of the written notice;
(D) The effective date of the facility closure or voluntary withdrawal of participation;
(E) The signature of the exiting operator's or owner's representative.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.501 | Compliance With Social Security Act Required.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
An operator shall comply with the "Social Security Act," section 1919(c)(2)(F), 42 U.S.C. 1396r(c)(2)(F) if the operator's nursing facility undergoes a voluntary withdrawal of participation.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.51 | Notice of Change of Operator.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) An exiting operator or owner and entering operator shall provide the department of medicaid written notice of a change of operator if the nursing facility participates in the medicaid program and the entering operator seeks to continue the nursing facility's participation. The written notice shall be provided to the department in accordance with the method specified in rules authorized by section 5165.53 of the Revised Code. The written notice shall be provided to the department not later than forty-five days before the effective date of the change of operator if the change of operator does not entail the relocation of residents. The written notice shall be provided to the department not later than ninety days before the effective date of the change of operator if the change of operator entails the relocation of residents.
The written notice shall include all of the following:
(1) The name of the exiting operator and, if any, the exiting operator's authorized agent;
(2) The name of the nursing facility that is the subject of the change of operator;
(3) The exiting operator's seven-digit medicaid legacy number and ten-digit national provider identifier number for the nursing facility that is the subject of the change of operator;
(4) The name of the entering operator;
(5) The effective date of the change of operator;
(6) The manner in which the entering operator becomes the nursing facility's operator, including through sale, lease, merger, or other action;
(7) If the manner in which the entering operator becomes the nursing facility's operator involves more than one step, a description of each step;
(8) Written authorization from the exiting operator or owner and entering operator for the department to process a provider agreement for the entering operator;
(9) The names and addresses of the persons to whom the department should send initial correspondence regarding the change of operator;
(10) If the nursing facility also participates in the medicare program, notification of whether the entering operator intends to accept assignment of the exiting operator's medicare provider agreement;
(11) The signature of the exiting operator's or owner's representative.
(B) An exiting operator or owner and entering operator immediately shall provide the department written notice of any changes to information included in a written notice of a change of operator that occur after that notice is provided to the department. The notice of the changes shall be provided to the department in accordance with the method specified in rules authorized by section 5165.53 of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.511 | Agreements With Entering Operators Effective on Date of Change of Operator.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
The department of medicaid may enter into a provider agreement with an entering operator that goes into effect at 12:01 a.m. on the effective date of the change of operator if all of the following requirements are met:
(A) The department receives a properly completed written notice required by section 5165.51 of the Revised Code on or before the date required by that section.
(B) The department receives both of the following in accordance with the method specified in rules authorized by section 5165.53 of the Revised Code and not later than ten days after the effective date of the change of operator:
(1) From the entering operator, a completed application for a provider agreement and all other forms and documents specified in rules authorized by section 5165.53 of the Revised Code;
(2) From the exiting operator or owner, all forms and documents specified in rules authorized by section 5165.53 of the Revised Code.
(C) The entering operator is eligible for medicaid payments as provided in section 5165.06 of the Revised Code.
2023 Ohio Revised Code › Title 51 | Public Welfare › Chapter 5165 | Medicaid Coverage of Nursing Facility Services › Section 5165.512 | Agreements With Entering Operators Effective on a Later Date.

Effective:
September 29, 2013
Latest Legislation:
House Bill 59 - 130th General Assembly
(A) The department of medicaid may enter into a provider agreement with an entering operator that goes into effect at 12:01 a.m. on the date determined under division (B) of this section if all of the following are the case:
(1) The department receives a properly completed written notice required by section 5165.51 of the Revised Code.
(2) The department receives, from the entering operator and in accordance with the method specified in rules authorized by section 5165.53 of the Revised Code, a completed application for a provider agreement and all other forms and documents specified in rules adopted under that section.
(3) The department receives, from the exiting operator or owner and in accordance with the method specified in rules authorized by section 5165.53 of the Revised Code, all forms and documents specified in rules adopted under that section.
(4) One or more of the following apply:
(a) The requirement of division (A)(1) of this section is met after the time required by section 5165.51 of the Revised Code;
(b) The requirement of division (A)(2) of this section is met more than ten days after the effective date of the change of operator;
(c) The requirement of division (A)(3) of this section is met more than ten days after the effective date of the change of operator.
(5) The entering operator is eligible for medicaid payments as provided in section 5165.06 of the Revised Code.
(B) The department shall determine the date a provider agreement entered into under this section is to go into effect as follows:
(1) The effective date shall give the department sufficient time to process the change of operator, assure no duplicate payments are made, and make the withholding required by section 5165.521 of the Revised Code.
(2) The effective date shall be not earlier than the latest of the following:
(a) The effective date of the change of operator;
(b) The date that the entering operator complies with section 5165.51 of the Revised Code and division (A)(2) of this section;
(c) The date that the exiting operator or owner complies with section 5165.51 of the Revised Code and division (A)(3) of this section.
(3) The effective date shall be not later than the following after the later of the dates specified in division (B)(2) of this section:
(a) Forty-five days if the change of operator does not entail the relocation of residents;
(b) Ninety days if the change of operator entails the relocation of residents.