Current through all regulations passed and filed through September 16, 2024
This rule describes how hospitals
are
classified into mutually exclusive peer groups for purposes of setting rates
and making payments under the "All Patient Refined-Diagnosis Related Group"
(APR-DRG) inpatient prospective payment system, the "Enhanced Ambulatory
Patient Grouping" (EAPG) outpatient prospective payment system or to those
hospitals excluded from the prospective payment systems.
(A) Definitions.
(1)
"Cancer hospitals"
are those hospitals recognized by medicare that primarily treat neoplastic
disease in accordance with 42 C.F.R.
412.23(f) effective October
1, 2022.
(2) "Children's
hospitals" are those hospitals that primarily serve patients eighteen years of
age and younger and that are excluded from medicare prospective payment in
accordance with 42 C.F.R.
412.23(d) effective October
1,
2022,
or are registered with the Ohio department of health in accordance with section
3701.07 of the Revised Code. A
children's hospital that has less than seventy-five beds and enrolled as a
medicaid provider on or after January 1, 2011,
will:
(a) For the purposes of setting base rates,
for inpatient services as described in rule
5160-2-65 of the Administrative
Code and outpatient services as described in rule
5160-2-75 of the Administrative
Code, be grouped into its natural
rural or
urban hospital
peer group as described in paragraph
(A)(7) or
(A)(9) of this
rule; and
(b) Receive any pricing
considerations or differentials as if they were in the children's hospital peer
group.
(3)
"Critical access hospitals" (CAH)
are those hospitals that are certified as a critical access hospital by the
centers for medicare and medicaid services (CMS) and excluded from medicare
prospective payment in accordance with
42 C.F.R.
400.202 effective October 1,
2022.
(4)
"Freestanding long-term acute care
hospitals" are those hospitals in which the department of health and human
services has determined to be excluded from medicare prospective payment in
accordance with 42 C.F.R.
412.23(e) effective October
1, 2022.
(5)
. "Freestanding psychiatric hospitals" are those hospitals
that are eligible to provide medicaid services as described in rule
5160-2-01 of the Administrative
Code and are grouped into their natural peer group as defined in paragraphs
(A)(2), (A)(3), (A)(7), (A)(8), and (A)(9) of this rule.
(6)
"Freestanding rehabilitation hospitals" are those hospitals in which the
department of health and human services has determined to be excluded from
medicare prospective payment in accordance with
42 C.F.R.
412.23(b) effective October
1,
2022.
(7)
"Rural hospitals" are those hospitals located in Ohio
counties that are not classified into core based statistical areas (CBSA) as
designated in the inpatient prospective payment system (IPPS) case-mix and wage
index table as published by CMS for the federal fiscal year beginning in the
calendar year immediately preceding the effective date of the hospital rates. A
copy of the medicare IPPS case-mix and wage index table by CMS certification
number (CCN) is available on the department's website at
medicaid.ohio.gov.
(8)
"Teaching hospitals" are those hospitals with a major
teaching emphasis that have at least two hundred beds and have an intern-and
resident-to-bed ratio of at least .35. For non-Ohio hospitals, only those
hospitals classified by the Ohio department of medicaid (ODM) as teaching
hospitals as of June 30, 2016, will be considered non-Ohio teaching
hospitals.
(9)
"Urban hospitals" are those hospitals located in Ohio
counties that are classified into CBSAs as designated in the IPPS case-mix and
wage index table as published by CMS for the federal fiscal year beginning in
the calendar year immediately preceding the effective date of the hospital
rates, and not otherwise defined in paragraphs (A)(2), (A)(3), (A)(7), and
(A)(8) of this rule.
(10) For
the purposes of this rule, the "number of beds" is the total number of beds
reported on the hospital's state fiscal year (SFY) 2014 Ohio medicaid hospital
cost report (ODM 02930, rev. 06/14).
(11) For the purposes of this rule, "interns
and residents" is the net number of interns and residents reported on the
hospital's SFY 2014 Ohio medicaid hospital cost report.
(B) Ohio hospital prospective payment peer
groups.
(1) Hospitals described in paragraphs
(B)(1)(a) to (B)(1)(e) of this rule
will be paid on a prospective payment basis for
inpatient services as described in rule
5160-2-65 of the Administrative
Code and for outpatient services as described in rule
5160-2-75 of the Administrative
Code.
(a) Critical access hospitals;
(b) Rural hospitals;
(c) Children's hospitals;
(d) Teaching hospitals;
(e) Urban hospitals, which are grouped based
on geographical regions listed in the appendix to this
rule.
(2) Hospitals
described in paragraphs (B)(2)(a) to (B)(2)(c) of this rule
will be
paid in accordance with rule
5160-2-22 of the Administrative
Code.
(a) Cancer hospitals;
(b) Rehabilitation hospitals;
(c) Long-term acute care
hospitals.
(C)
Reassignment of hospitals among peer groups.
On January first of each
year, any hospital geographically located in an Ohio county that has been
newly included or newly excluded from a CBSA, as designated in the IPPS
case-mix and wage index table as published by CMS for the federal fiscal year
beginning in the calendar year immediately preceding the effective date of the
hospital rates,
will be placed into either the rural peer group
as defined in paragraph
(A)(7) of this rule or, based on the geographical
location of the hospital, an urban peer group as defined in paragraph
(A)(9)
of this rule, for the new classification. The hospital's new base rate
will be
the average cost per discharge of the new peer group without any consideration
for hospital-specific risk provisions, as described in rule
5160-2-65 of the Administrative
Code and rule
5160-2-75 of the Administrative
Code, of either the new or previous peer group.
(D) Rates for new, acquired, replacement, and
merged hospitals.
(1) Hospitals new to
medicaid.
(a) Hospitals described in paragraph
(B)(1) of this rule that are newly enrolled with medicaid,
will be
classified into mutually exclusive peer groups as defined in paragraph (A) of
this rule. Until data is available to calculate hospital-specific rates, the
hospital
will receive:
(i) The
base rate of the peer group in which they are classified into without any
consideration for hospital-specific risk provisions as described in rule
5160-2-65 of the Administrative
Code for inpatient services and rule
5160-2-75 of the Administrative
Code for outpatient services,
(ii)
The statewide average for capital allowance in accordance with rule
5160-2-66 of the Administrative
Code, and
(iii) The statewide
average for both inpatient cost-to-charge ratio and outpatient cost-to-charge
ratio as described in paragraph (B)(2) of rule
5160-2-22 of the Administrative
Code.
(b) Hospitals
described in paragraph (B)(2) of this rule that are newly enrolled with
medicaid,
will receive ninety per cent of the calculated rates
as described in paragraph (D)(1)(a)(iii) of this rule until data is available
to calculate hospital-specific rates in
accordance with rule
5160-2-22 of the
Administrative Code.
(2) Acquired hospitals.
Hospitals that have a change of ownership
will
receive the prior owner's rates for reimbursement until a cost report is filed
by the new owner in accordance with rule
5160-2-23 of the Administrative
Code and rates are calculated in accordance with rule
5160-2-22 of the Administrative
Code.
(3) Replacement
hospitals.
If a new hospital facility is opened for the purpose of
replacing an existing (original) hospital facility identifiable to a unique
medicaid provider number and the original facility closes, the rates from the
original facility
will be used for reimbursement, if the conditions
of paragraphs (C)(4)(a) to (C)(4)(c) of rule
5160-2-09 of the Administrative
Code are met, and until a cost report is filed by the new owner in accordance
with rule
5160-2-23 of the Administrative
Code and rates are calculated in accordance with rule
5160-2-22 of the Administrative
Code.
(4) Hospital mergers.
When hospitals identifiable by a unique medicaid provider
number are involved in a merger, the rates for the surviving medicaid provider
number
will be used for reimbursement until a cost report is
filed in accordance with rule
5160-2-23 of the Administrative
Code and rates are calculated in accordance with rule
5160-2-22 of the Administrative
Code.
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Appendix
