reglab/statecodes huggingface dataset:
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-02.2 - Nursing facilities (NFs): termination, denial, and non-revalidation of provider agreements

Current through all regulations passed and filed through July 1, 2024
(A) Written notice.
(1) The Ohio department of
			 medicaid (ODM) may terminate, deny, or not
			 revalidate a NF provider
			 agreement upon thirty days written notice to the NF.
(2)
			 Notices and termination orders must comply with provisions set forth in
			 sections 
										5164.38
									 and
			 
										5165.77
									 of the Revised
			 Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-02.4 - Nursing facilities (NFs): mandatory dual participation in the medicare program

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) For purposes of this rule, the terms
			 "certified beds,"  "dually
			 participating," "facility," and "religious non-medical health care institution"
			 (RNHCI) are defined in rule 5160-3- 02.3 of the Administrative
			 Code.
(2) For purposes of this
			 rule, the term "reasonable assurance period" is defined in rule
			 5160-3- 02.1 of the Administrative Code.
(3) "Fully participating" means participation
			 of an institution in its entirety, either in the medicare or medicaid program,
			 or both. A fully participating skilled nursing facility (SNF) is one in which
			 every bed is certified for participation in medicare. A fully participating
			 nursing facility (NF) is one in which every bed is certified for participation
			 in medicaid. A fully participating SNF/NF is one in which every bed is
			 certified for participation in both medicare and medicaid.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-02.7 - Nursing facilities (NFs): emergency and disaster plan, resident relocation, and required notifications

Current through all regulations passed and filed through July 1, 2024
(A)
								 Purpose.
The purpose of this rule is to set
				forth provisions for the preparation for, response to, and recovery from an
				emergency or disaster at a NF. The provisions of this rule are in addition to
				the requirements set forth in sections
				5165.77,
				5165.80, and
				5165.81 of the Revised Code, and
				in rule
				3701-17-25
				of the Administrative Code.
(B)
								Emergencies and
			 disasters.
"Emergencies and disasters" are
				unexpected situations or sudden occurrences of a serious or urgent nature that
				create a substantial likelihood that one or more of a facility's residents may
				be harmed and/or may need to be relocated. Events that may constitute an
				emergency or disaster include, but are not limited to, the
				following:
(1)
									Tornado, severe wind, severe storm, flood, or other
			 natural disaster.
(2)
									Fire.
(3)
									Explosion.
(4)
									Loss of
			 electrical power.
(5)
									Release of hazardous chemicals or other hazardous
			 material.
(6)
									Outbreak of contagious disease.
(7)
									Civil disturbance
			 such as a riot.
(8)
									A labor strike that suddenly causes the number of staff
			 members in a facility to be below that necessary for resident
			 care.
(9)
									A missing resident, where there is the liklihood that
			 the resident may be harmed while absent from the facility.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-03.2 - Nursing facilities (NFs): resident protection fund and collection of fines

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions.
(1)
									"Fines" means civil money penalties (CMPs) and other
			 assessments imposed against a NF as a remedy for deficiencies or a cluster of
			 deficiencies that were not substantially corrected before a
			 survey.
(2)
									"Interest" means the interest rate determined by the
			 tax commissioner on the fifteenth day of October each year by rounding the
			 federal short-term rate to the nearest whole number per cent and adding three
			 per cent. This is the interest rate per annum used in computing the interest
			 that accrues during the following calendar year.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-04 - Nursing facilities (NFs): payment during the Ohio department of medicaid (ODM) administrative appeals process for denial or termination of a provider agreement

Current through all regulations passed and filed through July 1, 2024
(A) When ODM is required to provide an
			 adjudicatory hearing pursuant to Chapter 119. of the Revised Code, payment
			 shall continue for medicaid-covered services provided to eligible residents
			 during the appeal of, and the proposed termination or
			 non-revalidation of, a nursing facility (NF) provider
			 agreement. Payment shall not be made under this provision for services rendered
			 on or after the effective date of ODM issuance of a final order of adjudication
			 pursuant to Chapter 119. of the Revised Code, except as provided in paragraph
			 (B) of this rule.
(B) Payment may
			 be provided up to thirty days following the effective date of termination or
			 non-revalidation of a NF provider agreement; or after
			 an administrative hearing decision that upholds the ODM termination or
			 non-revalidation action. Payment will be available if
			 both of the following conditions are met:
(1)
			 Residents were admitted to the NF before the effective date of termination or
			 expiration; and
(2) The NF
			 cooperates with the state, local, and federal entities in the effort to
			 transfer residents to other NFs, institutions, or community programs that can
			 meet the residents' needs.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-04.1 - Nursing facilities (NFs): payment during the survey agency's administrative appeals process for termination or non-renewal of medicaid certification

Current through all regulations passed and filed through July 1, 2024
(A) For the purposes of this rule, the
			 following definitions shall apply:
(1) "State
			 survey agency" means for the purpose of medicaid certification, the Ohio
			 department of health (ODH).
(2)
			 "Effective date of termination" means the date set by the state survey agency
			 or the United States department of health and human services for the
			 termination of certification.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-05 - Level of care definitions

Current through all regulations passed and filed through July 1, 2024
(A)
								 This rule
			 contains the definitions used in the process of making a determination of an
			 individual's level of care. The definitions in this rule apply unless a term is
			 otherwise defined in a specific rule.
(B)
								
			 Definitions.
(1)
									 "Active Treatment" means a continuous treatment
			 program including aggressive, consistent implementation of a program of
			 specialized and generic training, treatment, health services and related
			 services for individuals with mental retardation and/or other developmental
			 disabilities that are directed toward the following:
(a)
										 The acquisition
			 of the behaviors necessary for the individual to function with as much self
			 determination and independence as possible; and
(b)
										 The prevention
			 or deceleration of regression or loss of current optimal functional
			 status.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-06 - Criteria for the protective level of care

Current through all regulations passed and filed through July 1, 2024
(A)
								 This rule
			 describes the criteria for an individual to meet the protective level of
			 care.
(B)
								 The criteria for the protective level of care is met
			 when:
(1)
									 The
			 individual's needs for long-term services and supports (LTSS), as defined in
			 rule 5101:3-3-05 of the Administrative Code, are less than the criteria for the
			 intermediate or skilled levels of care, as described in paragraphs (B)(4), (C),
			 and (D)(4) of rule 5101:3-3-08 of the Administrative Code.
(2)
									 The individual's
			 LTSS needs are less than the criteria for the ICF-MR-based level of care, as
			 defined in rule 5101:3-3-05 of the Administrative Code.
(3)
									 The individual
			 has a need for:
(a)
										 Less than twenty-four hour support, as defined in rule
			 5101:3-3-05 of the Administrative Code, in order to prevent harm due to a
			 cognitive impairment, as diagnosed by a physician or other licensed health
			 professional acting within his or her applicable scope of practice, as defined
			 by law; or
(b)
										 Supervision, as defined in rule 5101:3-3-05 of the
			 Administrative Code, of one activity of daily living (ADL), as defined in rule
			 5101:3-3-05 of the Administrative Code and as described in paragraph (C) of
			 this rule, or supervision of medication administration, as defined in rule
			 5101:3-3-05 of the Administrative Code; and
(c)
										 Assistance, as
			 defined in rule 5101:3-3-05 of the Administrative Code, with three instrumental
			 activities of daily living (IADL), as defined in rule 5101:3-3-05 of the
			 Administrative Code and as described in paragraph (D) of this rule.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-06.1 - Institutions for mental diseases (IMDs)

Current through all regulations passed and filed through July 1, 2024
(A)
								 The purpose of this rule is to set forth the process by
			 which the Ohio department of medicaid (ODM) shall identify nursing facilities
			 (NFs) that are at risk of becoming IMDs, the preventive measures to be taken by
			 ODM when such facilities have been identified, and the course of action to be
			 taken if a NF is identified as an IMD.
Medicaid payment is not available for
				services provided to individuals in an IMD who are age twenty-one and over, and
				in certain circumstances age twenty-two and over, and under age sixty-five,
				except as permitted in
				42 C.F.R.
				438.6(e) (October 1,
				2016).
(B)
			 Definitions.
(1) "At risk facility". A NF is
			 considered to be an at risk facility if it meets two or more of the IMD
			 evaluation criteria set forth in paragraph (C)(2)(b) of this rule but has not
			 been determined to meet the definition of IMD set forth in paragraph (B)(2) of
			 this rule.
(2) "Institution for
			 mental diseases (IMD)" means a hospital, nursing facility, or other institution
			 of more than sixteen beds that is primarily engaged in providing diagnosis,
			 treatment, or care of persons with mental diseases, including medical
			 attention, nursing care and related services. A NF is considered to be an IMD
			 if its overall character is that of a facility established and maintained
			 primarily for the care and treatment of individuals with mental diseases,
			 whether or not it is licensed as such. An intermediate care facility for the
			 mentally retarded (ICF-MR) is not an IMD.
(3) "Mental diseases" means diseases listed
			 as mental disorders in the "International Classification of Diseases, Tenth
			 Revision, Clinical Modification," or the most recent edition, with the
			 exception of mental retardation, senility, and organic brain syndrome. This
			 publication is available on the internet via the website
http://www.cdc.gov/nchs/icd/icd10cm.htm
.
(4) "Potentially at risk of
			 becoming an IMD". A NF is considered to be potentially at risk of becoming an
			 IMD if any one of the following applies:
(a)
			 The NF is licensed as a mental nursing home as defined in rule
			 3701-17-01 of the
			 Administrative Code;
(b) The NF was
			 identified as an at risk facility during a prior IMD review; or
(c) Forty-five per cent or more of the NF's
			 residents have been determined to need specialized services for serious mental
			 illness by the Ohio department of mental health and addiction services (ODMHAS)
			 in accordance with rules 5160-3-15.1, 5160-3- 15.2, and 5122-21-03 of the
			 Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-08 - Criteria for nursing facility-based level of care

Current through all regulations passed and filed through July 1, 2024
(A)
								 This rule describes the criteria for an individual to
			 meet the nursing facility (NF)-based level of care. The NF-based level of care
			 includes the intermediate and skilled levels of care. An individual is
			 determined to meet the NF-based level of care when the individual meets the
			 criteria as described in paragraphs (B) to (D) of this rule.
(B)
								 The criteria for
			 the intermediate level of care is met when:
(1)
									 The individual's
			 needs for long-term services and supports (LTSS), as defined in rule
			 5101:3-3-05 of the Administrative Code, exceed the criteria for the protective
			 level of care, as described in paragraph (B)(3) of rule 5101:3-3-06 of the
			 Administrative Code.
(2)
									 The individual's LTSS needs are less than the criteria
			 for the skilled level of care, as described in paragraph (D)(4) of this
			 rule.
(3)
									 The individual's LTSS needs do not meet the criteria
			 for the ICF-MR-based level of care, as defined in rule 5101:3-3-05 of the
			 Administrative Code.
(4)
									 The individual has a need for a minimum of one of the
			 following:
(a)
										
			 Assistance, as defined in rule 5101:3-3-05 of the Administrative Code, with the
			 completion of a minimum of two activities of daily living (ADL), as defined in
			 rule 5101:3-3-05 of the Administrative Code and as described in paragraph (C)
			 of this rule;
(b)
										 Assistance with the completion of a minimum of one ADL
			 as described in paragraph (C) of this rule, and assistance with medication
			 administration, as defined in rule 5101:3-3-05 of the Administrative
			 Code;
(c)
										 A minimum of one skilled nursing service or skilled
			 rehabilitation service, as defined in rule 5101:3-3-05 of the Administrative
			 Code; or
(d)
										 Twenty-four hour support, as defined in rule
			 5101:3-3-05 of the Administrative Code, in order to prevent harm due to a
			 cognitive impairment, as diagnosed by a physician or other licensed health
			 professional acting within his or her applicable scope of practice, as defined
			 by law.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-14 - Process and timeframes for a level of care determination for nursing facility-based level of care programs

Current through all regulations passed and filed through July 1, 2024
(A) This rule describes the processes and
			 timeframes for a level of care determination, as defined in rule
			 5160-3-05 of the Administrative Code, for a nursing
			 facility (NF)-based level of care program, as defined in rule
			 5160-3-05 of the Administrative Code.
(1) The processes described in this rule
			 will not
			 be used for a determination for an ICF-IID-based level of
			 care, as defined in rule 5160-3-05 of the Administrative Code.
(2) A level of care determination may occur
			 face-to-face , by a desk review, or by
			 telephone, as defined in rule 5160-3-05
			 of the Administrative Code, and is one component of medicaid eligibility in
			 order to:
(a) Authorize medicaid payment to a
			 NF; or
(b) Approve medicaid payment
			 of a NF-based home and community-based services (HCBS) waiver or other NF-based
			 level of care program.
(3) An individual who is seeking a NF
			 admission is subject to both a preadmission screening and resident review
			 (PASRR) process, as described in rules 5160-3-15,
			 5160-3- 15.1, 5160-3- 15.2, 5122-21-03, and
			 5123-14-01 of the Administrative Code, and a level of
			 care determination process.
(a) The
			 preadmission screening process must be completed before a level of care
			 determination or a level of care validation can be issued.
(b) In order for the Ohio department of
			 
										medicaid (ODM) to authorize payment to a NF, the
			 individual must have received a non-adverse PASRR determination and subsequent
			 NF-based level of care determination.
(i)
											ODM may
			 authorize payment to the NF effective on the date of the PASRR
			 determination.
(ii) The level of
			 care effective date cannot precede the date that the PASRR requirements were
			 met.
(iii) If a NF receives
			 medicaid payment from ODM or its designee
			 for an individual who does not have a NF-based level of care, the NF is
			 subject to the claim adjustment for overpayments process described in rule
			 5160-1-19 of the Administrative Code.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-15.1 - Preadmission screening requirements for individuals seeking admission to nursing facilities

Current through all regulations passed and filed through July 1, 2024
(A) The purpose of this rule is to set forth
			 the level I and level II preadmission screening requirements pursuant to
			 section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019, to
			 ensure that individuals seeking admission, as defined in rule
			 5160-3-15
			 of the Administrative Code, to a medicaid-certified nursing facility (NF) who
			 have serious mental illness (SMI) and/or a developmental disability (DD) as
			 defined in rules
			 5122-21-03
			 and
			 5123-14-01
			 of the Administrative Code are identified and not admitted to a NF unless a
			 thorough evaluation indicates that such placement is appropriate and adequate
			 services will be provided regardless of payor source.
(B) A level I screening as defined in rule
			 5160-3-15
			 of the Administrative Code is required:
(1)
			 Prior to any new admission, as defined in rule
			 5160-3-15
			 of the Administrative Code, to a NF.
(2) Prior to a categorical determination, as
			 defined in rule
			 5160-3-15
			 of the Administrative Code.
(3)
			 When an individual is directly admitted to a NF from any of the following:
(a) A hospital that is maintained, operated,
			 managed or governed by the Ohio department of mental health and addiction
			 services (OhioMHAS) under section
			 5119.14
			 of the Revised Code for the care and treatment of mentally ill persons;
			 or
(b) A free standing hospital, or
			 unit of a hospital licensed by OhioMHAS under section
			 5119.33
			 of the Revised Code; or
(c) An
			 out-of state psychiatric hospital or unit of such hospital.
(4) When a non Ohio resident is seeking
			 admission to an Ohio NF from an out-of-state NF.
(a) If the non Ohio resident has been
			 determined or suspected to have a SMI and/or DD by the other state, the other
			 state's level II evaluation(s) of the individual and any additional supporting
			 documentation should be submitted with the preadmission request.
(b) Submission of the required forms and
			 documentation does not constitute completion of the level I process.
(c) The NF can not admit an individual until
			 the PASRR screening process as defined in rule
			 5160-3-15
			 of the Administrative Code is complete and a determination for the individual
			 is received by the NF pursuant to section 1919(e)(7) of the Social Security
			 Act, as in effect July 1, 2019.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-15.2 - Resident review requirements for individuals residing in nursing facilities

Current through all regulations passed and filed through July 1, 2024
(A)
								The purpose of
			 this rule is to set forth resident review requirements in compliance with
			 section 1919(e)(7) of the Social Security Act, as in effect on July 1, 2019,
			 which prohibits nursing facilities (NF) from retaining individuals with serious
			 mental illness (SMI) as defined in rule
			 5160-3-15
			 of the Administrative Code and/or developmental disabilities (DD) as defined in
			 rule 5160-3-15 of the Administrative Code unless a thorough evaluation
			 indicates that such placement is appropriate and adequate services are
			 provided. A resident review will be completed whenever an individual
			 experiences a significant change in condition as defined in rule
			 5160-3-15
			 of the Administrative Code and that change has a material impact on their
			 functioning as it relates to their mental illness or developmental disability
			 status.
(B)
								Resident review requirements.
(1)
									No individual
			 with SMI or DD can be retained as a resident in a nursing facility (NF),
			 regardless of payment source, unless it has been determined in accordance with
			 rules
			 5122-21-03
			 and 5123:14-01 of the Administrative Code, that:
(a)
										The individual
			 needs the level of services provided by a NF; or
(b)
										The individual
			 had resided in a NF for at least thirty months at the time of the first
			 resident review determination that established that the individual does not
			 require the level of services provided by a NF, and
(i)
											Requires
			 specialized services only; and
(ii)
											The individual
			 has chosen to remain in a NF after being informed of service alternatives to NF
			 placement.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-15.5 - ICF-MR Level of care determination process for home and community based medicaid waivers administered by the Ohio department of mental retardation and developmental disabilities

Current through all regulations passed and filed through July 1, 2024
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-16.3 - Nursing facilities (NFs): private rooms

Current through all regulations passed and filed through July 1, 2024
(A) Medical necessity.
(1) A nursing facility (NF) operator shall
			 provide private room accommodations, if
			 available, for a medicaid eligible resident if the resident requires a
			 private room due to medical necessity such as the need
			 for infection control.
(2)
			 Medicaid payment shall be considered payment in full, and no supplemental
			 payment may be requested or accepted from a resident or from a resident's authorized representative or
			 family.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-16.5 - Nursing facilities (NFs): personal needs allowance (PNA) accounts and other resident funds

Current through all regulations passed and filed through July 1, 2024
A NF resident's rights concerning his or her personal financial
				affairs shall be in accordance with
				42 CFR 483.10
				(October 4, 2016).
(A) Definitions.
(1) "Personal needs allowance (PNA) account" means an account or petty cash fund that
			 holds the money of a NF resident and is managed for the resident by the NF
			 provider.
(2) "Letters of administration," also known as letters
			 testamentary, means court papers allowing a person to take charge of the
			 property of a deceased person in order to distribute it.
(3)
			 "Surety bond" means an agreement between the principal (i.e., the NF provider),
			 the surety (i.e., the insurance company), and the obligee (i.e., the resident
			 and/or the Ohio department of medicaid (ODM) acting on behalf of the resident),
			 wherein the principal and the surety agree to compensate the obligee for any
			 loss of the obligee's funds that the principal holds, safeguards, manages, and
			 accounts for.
The purpose of a surety bond is to guarantee that a NF provider
				will pay a resident, or ODM on behalf of a resident, for losses occurring from
				any failure by the facility to hold, safeguard, manage, and account for the
				resident's funds, including losses incurred as a result of acts of error or
				negligence, incompetence, or dishonesty. The principal assumes the
				responsibility to compensate the obligee for the amount of the loss up to the
				entire amount of the surety bond.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-17.1 - Outlier services in nursing facilities for individuals with severe maladaptive behaviors due to traumatic brain injury (NF-TBI services)

Current through all regulations passed and filed through July 1, 2024
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-17.3 - Out-of-state nursing facility (NF) services for individuals with traumatic brain injury (TBI)

Current through all regulations passed and filed through July 1, 2024
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-18 - Nursing facilities (NFs): ventilator program

Current through all regulations passed and filed through July 1, 2024
(A) Purpose.
In accordance with section
				5165.157 of the Revised Code,
				this rule establishes an alternative purchasing model for the provision of
				nursing facility (NF) services to ventilator dependent individuals which may
				include ventilator weaning.
(B) Definitions.
For purposes of this rule the following definitions
				apply:
(1) "Discrete unit" means an
			 area in a NF that is set aside from the larger facility. A discrete unit may be
			 a separate building, wing, floor, hallway, one side of a corridor, or a room or
			 group of rooms. Beds in the unit may be utilized for individuals who are not
			 ventilator dependent provided that the NF can accommodate all the ventilator
			 dependent individuals covered under this rule and as required by this rule.
(2) "ODM NF ventilator program"
			 means the ventilator services, which may include ventilator weaning services,
			 provided to ventilator dependent individuals by a NF in accordance with this
			 rule, where the NF is eligible to receive an enhanced payment rate for
			 providing those services.
(3)
			 "Respiratory care professional" (RCP) means the same as in division (B) of
			 section 4761.01 of the Revised
			 Code.
(4) "Ventilator-associated
			 pneumonia (VAP)" means pneumonia in an individual intubated and ventilated at
			 the time of, or within forty-eight hours before, the onset of the
			 pneumonia.
(5) "VAP baseline rate"
			 means the average of a NF's VAP rate for a fiscal year calculated by ODM using
			 the data from the submission of quarterly reports for the most recent full
			 calendar year beginning January first and ending December
			 thirty-first.
(6) "VAP threshold
			 rate" means a maximum number of VAP episodes determined by ODM based on the VAP
			 baseline rates for all NFs statewide.
(7) "VAP rate" means the number of VAP
			 episodes occurring in the NF per one-thousand ventilator days.
(8) "Ventilator dependent" means the use of
			 any type of mechanical ventilation to sustain daily respiration for any part of
			 the day.
(9) "Ventilator weaning"
			 means the gradual withdrawal of ventilator support.
(10) "Ventilator weaning services" means the
			 services provided to support the individual resident's ventilator weaning and
			 includes a post ventilator weaning evaluation period of up to fourteen
			 days.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-19 - Nursing facilities (NFs): relationship of NF services to other covered medicaid services

Current through all regulations passed and filed through July 1, 2024
This rule identifies covered services generally available to
				medicaid recipients and describes the relationship of such services to those
				provided by a NF. Whenever reference is made to payment for services through
				the NF per diem, the rules governing such payment are set forth in Chapter
				5160-3 of the Administrative Code.
(A)
			 Acupuncture services.
All covered acupuncture services provided by an eligible
				acupuncture provider are paid directly to the provider of acupuncture services
				in accordance with rule
				5160-8-51 of
				the Administrative Code.
(B)
			 Behavioral health services.
Costs for behavioral health services are paid directly to the
				provider of services, not through the NF per diem.
(C) Dental services.
All covered dental services provided by licensed dentists are
				paid directly to the provider of the dental services in accordance with Chapter
				5160-5 of the Administrative Code. Personal hygiene services related to dental
				services provided by facility staff or contracted personnel are paid through
				the NF per diem.
(D)
			 Laboratory and x-ray services.
Costs incurred for the purchase and administration of
				tuberculin tests, and for drawing specimens and forwarding specimens to a
				laboratory, are paid through the NF per diem. All costs of laboratory and x-ray
				procedures covered under the medicaid program are paid directly to the
				laboratory or x-ray provider in accordance with Chapter 5160-11 of the
				Administrative Code.
(E)
			 Medical supplier services.
In accordance with rule
				5160-10-02 of the
				Administrative Code, costs of certain medical supplies are paid through the NF
				per diem, and others are paid directly to the medical supply provider as
				follows:
(1) Items that must be paid
			 for through the NF per diem include:
(a)
			 "Medical supplies," defined as those items that have a very limited life
			 expectancy, such as atomizers, nebulizers, bed pans, catheters, hypodermic
			 needles, syringes, incontinence pads, splints, and disposable ventilator
			 circuits.
(b) "Needed medical
			 equipment" (and repair of such equipment), defined as items that can stand
			 repeated use, are primarily and customarily used to serve a medical purpose,
			 are not useful to an individual in the absence of illness or injury, and are
			 appropriate for use in the facility. Such medical equipment items include
			 hospital beds, wheelchairs other than custom wheelchairs, and intermittent
			 positive-pressure breathing machines, except as noted in paragraph (E)(2) of
			 this rule.
(c) Emergency stand-by
			 oxygen.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-22 - Rate recalculations, interest on overpayments, penalties, repayment of overpayments, and deposit of repayment of overpayments for nursing facilities (NFs)

Current through all regulations passed and filed through July 1, 2024
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-24 - Nursing facilities (NFs): prospective rate reconsideration for possible calculation errors

Current through all regulations passed and filed through July 1, 2024
(A) A nursing
			 facility provider,  or a group or
			 association of nursing facility providers, may
			 request a reconsideration of a prospective NF rate on the basis of a possible
			 error in the calculation of the rate as follows:
(1) A request for reconsideration
			  shall be filed with the Ohio
			 department of medicaid (ODM) no more than thirty days after the later of the
			  date on the rate setting
			 package notification or the effective date of the
			 rate.
(2) The request for a
			 reconsideration  shall be filed in
			 accordance with the following procedures:
(a)
			 The request for rate reconsideration shall be in writing; and
(b) The request shall be addressed to "Ohio
			 Department of Medicaid, Fiscal Operations - LTC Rate Methodology Unit, P.O. Box
			 182709, Columbus, Ohio 43215-3414"; and
(c) The request shall indicate that it is a
			 request for rate reconsideration due to a possible error in the calculation of
			 the rate; and
(d) The request shall
			 include a detailed explanation of the possible error and the proposed corrected
			 calculation; and
(e) The request
			 shall include references to the relevant sections of the Revised Code
			 or paragraphs of the Administrative
			 Code as appropriate.
(3) ODM shall respond in writing within sixty
			 days of receiving each written request for reconsideration
			 . If ODM requests additional information to
			 determine whether a rate adjustment is warranted, the NF shall respond in
			 writing and shall provide additional supporting documentation no more than
			 thirty days after the receipt of the request for additional information. ODM
			 shall respond in writing within sixty days of receiving the additional
			 information to the request for reconsideration .
(4) If a rate
			 adjustment is warranted as the result of a reconsideration of a prospective
			 rate , the adjustment shall be implemented retroactively to the
			 initial service date for which the rate is effective.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-30.1 - Nursing facilities (NFs) and hospital long term care units appeal of the franchise permit fee (FPF) determination or re-determination

Current through all regulations passed and filed through July 1, 2024
(A) When submitting
			 an appeal of a FPF determination or re-determination for a nursing home or
			 hospital long term care unit in accordance with section
			 
									5168.53
								 of the Revised
			 Code, a facility operator shall follow these procedures:
(1) The appeal shall be in writing and must
			 be received by 
									the Ohio department of medicaid (ODM) not later
			 than fifteen days after the date on which the FPF assessment notice was
			 mailed.
(2) The appeal shall be
			 submitted to 
									ODM and addressed to the organization listed in the
			 instructions that are sent with the assessment notice. If this address is
			 invalid, the facility shall contact the ODM
			 bureau of long term  services and
			 supports (BLTSS).
(3) The appeal shall indicate
			  it is an appeal of the FPF due to a
			 possible material error in determining the amount of the fee.
(4) The appeal shall include a detailed
			 explanation of the possible material error and the proposed correction of the
			 amount of the fee.
(5) The appeal
			 shall include references to the relevant sections of the Revised Code or rules
			 of the Administrative Code that support the position of the appeal.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-30.4 - Nursing facilities (NFs), nursing homes (NHs), and long term care hospital beds: procedure for terminating the franchise permit fee (FPF)

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
"Effective FPF termination date" (EFTD) means the date on which
				the centers for medicare and medicaid services (CMS) determines that the FPF
				does not qualify for federal financial participation.
(B) Determination of the FPF as an
			 impermissible health care related tax.
If CMS determines that the FPF is an impermissible health care
				related tax, the Ohio department of medicaid (ODM) shall
				take all necessary actions to cease implementation of the FPF program, pursuant
				to section 
										5168.42
									 of the Revised
				Code.
(C) Notification.
ODM shall notify each facility previously
				assessed the FPF of the effective date of the termination of the FPF program,
				and what impact this change will have on the facility.
(D) Reconciliation procedure.
ODM shall conduct an accounting of the funds paid
				to or collected from each facility as a result of the FPF program and shall do
				all of the following:
(1) Reconcile
			 FPFs paid by NFs, NHs, and hospitals.
(a) The
			 annual assessment of the FPF shall be prorated on a daily basis.
(b) FPF assessments for the days preceding
			 the EFTD shall remain due and payable.
(c) Collection shall be pursued in accordance
			 with sections 
											5168.51
										 and
			 
											5168.55
										 of the Revised
			 Code.
(d) FPF assessments issued
			 for days on and after the EFTD shall be rescinded.
(i)
											
											ODM shall issue refunds to NHs and hospitals for
			 any FPF remittances representing payment for daily fees on or beyond the EFTD,
			 unless a NF or skilled nursing facility/nursing facility (SNF/NF) has already
			 received medicaid payment for service dates described in paragraph (D)(3) of
			 this rule.
(ii) The source of the
			 refunds shall be the funds established by the FPF assessments as set forth in
			 section 
												5168.54
											
											of the Revised Code, if
			 necessary, to each NH and hospital assessed the FPF.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-32 - Nursing facilities (NFs): debt estimation methodology

Current through all regulations passed and filed through July 1, 2024
(A) The Ohio department of medicaid (ODM)
			 uses
			 the debt estimation methodology set forth in this rule to estimate the exiting
			 operator's actual and potential debts to ODM and the United States centers for
			 medicare and medicaid services (CMS) under the medicaid program in cases of a
			 change of operator, facility closure, voluntary termination, involuntary
			 termination, or voluntary withdrawal.
(B) ODM 
								totals the value of all of the
			 following that are determined applicable in calculating the debt estimate:
(1) Overpayments determined due to ODM
			 pursuant to section 5165.108 of the Revised Code,
			 including the following:
(a) Overpayments owed
			 to ODM for adjudicated final fiscal audit periods.
(b) Overpayments identified in proposed
			 adjudication orders that have been issued but not adjudicated.
(c) Overpayment amounts for any outstanding
			 periods where a final fiscal audit has not yet been issued. Such amounts are
			 estimated by generating preliminary reports of amounts owed by the exiting
			 operator for the applicable periods.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-32.2 - Nursing facilities (NFs): successor liability agreements for operators

Current through all regulations passed and filed through July 1, 2024
(A)
								Successor liability agreements entered into pursuant to
			 section 5165.521 of the Revised Code are
			 subject to approval by the Ohio department of medicaid (ODM).
(B)
								Successor
			 liability agreements must be signed by the exiting operator, ODM, and the
			 entity assuming liability pursuant to section
			 5165.521 of the Revised
			 Code.
(1)
									Only
			 the ODM successor liability agreement forms (rev. November, 2014, available at
http://medicaid.ohio.gov/PROVIDERS/ProviderTypes/LongTerm
CareFacilities/SuccessorLiabilityAgreements.aspx) may be
			 used for successor liability agreements entered into pursuant to section
			 5165.521 of the Revised Code.
			 The ODM language on the successor liability agreement forms shall not be
			 changed, modified, or altered in any way.
(2)
									Nursing facility
			 operators shall furnish the original signed successor liability agreement form
			 to ODM. Forms shall be submitted to "Ohio Department of Medicaid, Bureau of
			 Network Management, P.O. Box 182709, Columbus, OH. 43218-2709." In cases of a
			 facility closure the form shall be submitted to the attention of "LTC
			 Enrollment Coordinator." In cases of a change of operator the form shall be
			 submitted to the attention of "LTC CHOP Coordinator."
Replaces: 5160-3- 32.2
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-33 - Nursing facilities (NFs): reimbursement of NF relief payments upon sale of business or bed license

Current through all regulations passed and filed through July 1, 2024
(A)
								For purposes of
			 Section 220.60 of Amended Substitute
			 House Bill 169 of the 134th General Assembly and this rule, a "sale" occurs
			 when a purchase agreement or similar document that outlines the terms of the
			 purchase and results in the payment of money for the business or bed license,
			 is signed or, if the signature is not dated, the effective date specified in
			 the purchase agreement or similar document.
(B)
								Any nursing
			 facility that sells any of its business or bed licenses in accordance with
			 paragraph (A) of this rule from March 29, 2022 through June 30, 2023 will
			 reimburse the state in the following manner:
(1)
									If the proceeds
			 from the sale are less than the relief payment received by the nursing facility
			 pursuant to Section 220.60 of Amended Substitute
			 House Bill 169 of the 134th General Assembly, the nursing facility will
			 reimburse the state the full amount of the sale proceeds;
(2)
									If the proceeds
			 from the sale are greater than the relief payment received by the nursing
			 facility pursuant to Section
			 220.60 of Amended Substitute
			 House Bill 169 of the 134th General Assembly, the nursing facility will
			 reimburse the state the full amount of the relief payment and retain any amount
			 remaining from the sale after the relief payment is reimbursed in
			 full.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-39 - Payment and adjustment process for nursing facilities (NFs)

Current through all regulations passed and filed through July 1, 2024
(A) Forms.
For dates of services preceding July 1, 2005, NFs shall submit
				the form "Nursing Facility Payment and Adjustment Authorization" (JFS 09400,
				rev. 10/2012) directly to the Ohio department of job and
				family services (ODJFS) for the reimbursement of services.
The county department of job and family services (CDJFS)
									and NFsshall use the "Facility/CDJFS
				Transmittal" (JFS 09401, rev. 4/2011) form to exchange information necessary to
				complete the billing process for payment.
(B) Notification of admission.
The facility shall notify the CDJFS using the JFS 09401 form
				within five business days of admission of a new resident who is medicaid
				eligible or who has an application for medicaid that is pending even if care
				may initially be covered under a medicare benefit.
(C) Notification of death.
The NF  shall
				notify the CDJFS of the death of a medicaid resident by completing the JFS
				09401 and forwarding it to the CDJFS within five business days following the
				death of the resident. The CDJFS shall terminate medicaid eligibility within
				ten days after the receipt of the JFS 09401.
For dates of service preceding July 1, 2005, the CDJFS shall
				stop vendor payment within ten days after the receipt of the JFS 09401.
(1) The CDJFS shall complete and return the
			 JFS 09401, when appropriate, to the NF  within ten days of the receipt of the JFS 09401 for any
			 required payment adjustment.
(2)
			 The NF  shall complete the JFS
			 09400, when appropriate (e.g., final payment adjustment), within thirty days of
			 the receipt of the JFS 09401 and submit it to the address listed on the bottom
			 of form JFS 09400.
Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-39.1 - Nursing facilities (NFs): claim submission

Current through all regulations passed and filed through July 1, 2024
(A)
								Nursing
			 facilities shall submit claims in accordance with rule
			 5160-1-19 of the Administrative
			 Code. Additional requirements specific to the submission of long-term care per
			 diem claims are in paragraphs (B) to (E) of this rule.
(B)
								Additional
			 requirements to be met prior to submitting claims for services included in the
			 per diem.
(1)
									Individual is a medicaid recipient for the dates of
			 service.
(2)
									Individual is not in a restricted medicaid coverage
			 period (RMCP).
(3)
									Preadmission screening and resident review (PASRR) is
			 completed in accordance with rules
			 5160-3-15,
			 5160-3-15.1 and 5160-3-15.2 of the Administrative
			 Code.
(4)
									 NF-based level of care is completed in accordance with
			 rules 5160-3-05,
			 5160-3-06,
			 5160-3-08, and
			 5160-3-14 of the Administrative
			 Code.