This rule applies to all hospital services excluded from
the inpatient hospital and outpatient hospital,
diagnosis related prospective payment systems.
(A)
Applicability.
(1)
Cost-related
Reasonable
cost reimbursement,
for services provided
on or before September 30, 2014, where
interim payments are made
for services to approximate cost based on a historical
cost-to-charge ratio, and where
no reasonable costs actually incurred during a period are
subsequently
subsequent reconciled
reconciliation
occurs
to interim payments, applies
to:
(a) All outpatient hospital services
provided by
non-Ohio hospitals excluded
from
inpatient
outpatient prospective payment as set forth in rule
5160-2- 07.1
5160-2-05 of the Administrative Code
which file the JFS 02930 cost report.
(b) All outpatient hospital services
provided by Ohio hospitals excluded from inpatient prospective payment as set
forth in rule 5160-2-07.1 of the Administrative Code.
(c)
(b)
All
Inpatient
inpatient
hospital services provided by hospitals excluded from
inpatient prospective payment as set forth in
rule
5160-2- 07.1
5160-2-05 of the Administrative Code.
(d) Inpatient capital-related costs
as set forth in rule 5160-2-07.6 of the Administrative Code.
(2) Cost-related reimbursement,
where interim payments are made to approximate cost based on a historical
cost-to-charge ratio but where no subsequent reconciliation occurs, applies
to:
(a) Outpatient hospital services
provided by non-Ohio hospitals excluded from inpatient prospective payment as
set forth in rule 5160-2-07.1 of the Administrative Code which do not file the
JFS 02930 cost-report.
(b) Certain outpatient hospital
services as as described in rule 5160-2-21 of the Administrative
Code.
(3) Services described in paragraph
(A)(1) of this rule and provided on or after October 1, 2014 shall not be
subsequently reconciled.
(B) Payments under non-DRG prospective
payment.
(1) For hospital services provided
on or before September 30, 2014, providers will receive an interim payment as
described in paragraph (B)(2) of this rule. These interim payments will be
reconciled to the lower of reasonable cost incurred on behalf of medicaid
recipients during the time period or total allowed charges for medicaid
recipients during the time period.
(2)(1)
Interim payments
Payments for services subject to non-DRG prospective
payment are made by applying a historic cost-to-charge ratio to hospital
allowed charges.
(a) For outpatient services,
the ratio used is medicaid outpatient costs as reported on
JFS
ODM 02930,
schedule H, section II divided by medicaid outpatient charges as reported on
JFS
ODM 02930,
schedule H, section II. For inpatient hospital services, the ratio used is
medicaid inpatient costs, as reported on the JFS
ODM 02930,
schedule H, section I, divided by medicaid inpatient charges as reported on the
JFS
ODM 02930,
schedule H, section I.
(b) For
those hospitals which do not file the JFS
ODM 02930
cost-report, the ratio used is the statewide average. For outpatient services,
the ratio used is the sum of medicaid outpatient costs as reported on
JFS
ODM 02930,
schedule H, section II for all Ohio hospitals, divided by the sum of medicaid
outpatient charges as reported on JFS
ODM 02930, schedule H, section II for all Ohio
hospitals. For inpatient hospitals services, the ratio used is the sum of
medicaid inpatient costs as reported on the JFS
ODM 02930,
schedule H, section I for all Ohio hospitals, divided by the sum of medicaid
inpatient charges as reported on the JFS
ODM 02930,
schedule H, section I for all Ohio hospitals.
(c) The ratio used for
an interim
a
claim payment will be the ratio that is operational in the claims processing
system on the date the claim is paid and effective on the date of admission.
The ratios which are operational during a prospective rate year in the claims
processing system reflect data from each hospital's cost-report filed with the
department during the calendar year proceeding the year during which the
prospective rate year begins.
(3)(2)
For
services provided on or after October 1, 2014
by hospitals subject to non-DRG prospective payment, the historical
cost-to-charge ratio described in paragraph (B)
(2)
(1) of this rule
shall be either:
(a) Ninety per cent of the
calculated cost-to-charge ratio for freestanding rehabiliation
rehabilitation hospitals and freestanding long-term
acute care hospitals, as defined in rule
5160-2- 07.2
5160-2-05 of the Administrative Code;
or
(b)
Ninety-one and
seven tenths per cent of the calculated cost-to-charge ratio Or for cancer hospitals, as defined in rule
5160-2- 07.2
5160-2-05 of the Administrative Code
,
.
the reimbursement rate shall be:
(i) Ninety-seven per cent of the
calculated cost-to-charge ratio for discharges on or after October 1, 2014 and
on or before June 30, 2015;
(ii) Ninety-four per cent of the
calculated cost-to-charge ratio for discharges on or after July 1, 2015 and on
or before June 30, 2016;
(iii) Ninety-one and seven tenths
per cent of the calculated cost-to-charge ratio for discharges on or after July
1, 2016.
(C) In general, reasonable cost reimbursement
recognizes costs that are reasonable and allowable under Title XVIII standards
and principles described in 42
CFR
C.F.R413.1
through
to413.40
effective as of October 1,
2013
2018, except as otherwise provided in this paragraph.
These Title XVIII standards and principles are applicable to those covered
inpatient and outpatient hospital services as identified in Chapter 5160-2 of
the Administrative Code which are subject to
reasonable cost
-related
reimbursement as described in this rule.
(1) The costs identified in paragraphs
(C)(1)(a) to (C)(1)(f) of this rule are nonallowable.
(a) Cost of goods or services furnished free,
by the hospital, or at less than fair market value. For example, the cost of
office space or hospital employee time used to prepare physician invoices for
physicians who invoice the department on a fee-for-service basis.
(b) Cost of services not reimbursable due to
not having been billed timely as defined in rule 5160-1- 19.3
5160-1-19 of the Administrative Code.
(c) Cost of services which would be or are
covered by a third-party payer as described in rule
5160-1-08 of the Administrative
Code.
(d) The amount of any
interest expense for money borrowed to alleviate cash flow problems resulting
from rate reductions imposed for delinquent filing of cost reports as provided
in rule
5160-2-23 of the Administrative
Code.
(e) The amount of any
interest on overpayments and any interest expense for money borrowed to
alleviate cash flow problems resulting from an interest assessment as defined
in rule 5160-2-25
5160-1-25 of the Administrative Code.
(f) Costs which exceed limits described in 42
CFR
C.F.R.413.30 effective as of October 1,
2013
2018
except that the department may exempt certain facilities from these limits as
described in 42 CFR
C.F.R.413.30. The determinations to exempt facilities
according to 42 CFR
C.F.R.413.30 will be made during the final settlement
process.
(2) Provisions
of Title XVIII related to prospective payment for inpatient hospital services
as described in 42 CFR
C.F.R.412.1through
to412.125
effective as of October 1, 2013
2018 are not applicable to hospital services
reimbursed under the provisions of this rule. Hospital services described in
this rule are reimbursed under the provisions described in paragraphs (C) to
(C)(1)(f) of this rule except in instances when those regulations have been
altered to accommodate the Title XVIII prospective payment system.
Notes
Ohio Admin. Code
5160-2-22
Effective:
12/5/2019
Five Year Review (FYR) Dates:
9/5/2019 and
12/05/2024
Promulgated
Under: 119.03
Statutory
Authority: 5164.02
Rule
Amplifies: 5164.02
Prior
Effective Dates: 06/03/1983, 10/01/1983 (Emer.), 12/29/1983 (Emer.),
02/01/1984, 10/01/1984, 07/29/1985, 07/03/1986, 10/19/1987, 04/23/1988,
07/01/1988 (Emer.), 09/29/1988, 07/01/1989, 09/03/1991 (Emer.), 11/10/1991,
07/01/1992, 05/01/2000, 01/01/2005,
08/21/2014
