Ohio Admin. Code 5160-3-04.1 - Nursing facilities (NFs): payment during the survey agency's administrative appeals process for termination or non-renewal of medicaid certification

(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.

(B) When medicaid certification is either terminated or not renewed, ODJFS the Ohio department of medicaid (ODM) must also either terminate or not renew revalidate the medicaid provider agreement.

(C) The following requirements apply:

(1) During the appeals process provided by the state survey agency for the proposed termination or non-renewal of certification, payment for covered services provided to eligible residents is available if:

(a) Payment is for those residents admitted prior to the effective date of an order issued under section 5111.46 5165.72 , 5111.48 5165.74 , 5111.51 5165.77 , and or5111.57 5165.84 of the Revised Code, placing a ban on admissions to medicaid eligible residents and/or for certain diagnostic groups with specialized care needs denying medicaid payments to the facility for all medicaid eligible residents admitted after the effective date of the order; and

(b) The appeal is conducted prior to the effective date of termination or non-renewal.

(2) If the NF appeal process results in an adjudication order that upholds the ODH action or if the administrative hearing is not completed prior to the certification termination/non-renewal date, payment for services provided to eligible residents may be available for an additional thirty days if:

(a) The eligible resident was admitted prior to the termination/non-renewal date and prior to any ban on admissions as described effective date of an order that was issued as specified in paragraph (C)(1)(a) of this rule; and

(b) 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.

(3) If a NF's appeal of the termination or non-renewal of its certification is upheld, payment for covered services provided to eligible residents is resumed. If the appeal decision is reached after the termination/ non-renewal date, payment is made retroactive to the date of termination.

(4) When the state survey agency certifies that there is jeopardy to residents' health and safety by issuing an order under Chapter 5111. 5165. of the Revised Code, or when it fails to certify that there is no jeopardy, payment will end on the effective date of termination.

(5) When ODJFS ODM acts under instructions from the United States department of health and human services, payment ends on the date specified by that agency.

Notes

Ohio Admin. Code 5160-3-04.1

Effective: 12/10/2017
Five Year Review (FYR) Dates: 9/22/2017 and 12/10/2022
Promulgated Under: 119.03
Statutory Authority: 5165.02
Rule Amplifies: 5165.72, 5165.74, 5165.77, 5165.84
Prior Effective Dates: 3/18/88 (Emer.), 6/16/88, 1/1/95, 7/1/00, 7/1/03, 7/1/08, 1/10/13