Current through all regulations passed and filed through September 16, 2024
(A) The definitions
of all terms used in this rule are the same as set forth in rules 5160-3-01,
5160-3-43.1, and 5160-3- 43.4 of the Administrative Code.
(B) To determine resident case mix scores,
the Ohio department of medicaid (ODM) shall process resident assessment data
submitted by NFs in accordance with rule
5160-3-43.1 of the
Administrative Code, and shall classify residents in accordance with rule
5160-3-43.2 of the
Administrative Code. These resident case mix scores, based on relative resource
weights calculated in accordance with rule
5160-3-43.2 of the
Administrative Code, are used to establish two quarterly facility average case
mix scores each quarter.
(1) The first
quarterly facility average case mix score shall be calculated using all records
selected for the quarter and shall be the quarterly facility average total case
mix score.
(2) The second quarterly
facility average case mix score shall be calculated using only the records
selected for the quarter that ODM identifies as medicaid records and shall be
the quarterly facility average medicaid case mix score.
(C) ODM shall calculate a quarterly facility
average total case mix score for all providers meeting the following
requirements:
(1) In accordance with rule
5160-3-43.1 of the
Administrative Code, the provider submitted resident assessment information by
the filing date, and the data included resident assessments for all residents
in medicaid certified beds as of the reporting period end date, and
(a) The provider's resident assessment data
submitted timely for that reporting quarter provided sufficient information for
accurately classifying at least ninety per cent of all residents in medicaid
certified beds into RUG non-default groups, or
(b) The provider's resident assessment data
submitted timely and corrected timely, in accordance with the procedures
outlined in rule
5160-3-43.1 of the
Administrative Code for correcting incomplete or inaccurate information, for
that reporting quarter, provided sufficient information for accurately
classifying at least ninety per cent of all residents in medicaid certified
beds into RUG non-default groups; and
(c) There were no errors that prevented ODM
from verifying the records to be used in determining the quarterly facility
average total case mix score.
(d)
The prospective payment system (PPS) other medicare required assessments
(OMRAs) may not be selected for calculating case mix
scores.
(2) The quarterly
facility average total case mix score for providers that submitted their
minimum data set version 3.0 (MDS 3.0) data in compliance with paragraph (C)(1)
of this rule shall be calculated as follows:
(a) All resident case mix scores for the
quarter, including resident case mix scores in the RUG default group, are added
together; then
(b) The sum of
resident case mix scores is divided by the total number of residents.
(3) If a provider does not comply
with paragraph (C)(1) of this rule, ODM
may assign the
NF a penalty score. If assigned,
the
penalty score for the quarterly facility average total case mix score shall be
a score that is five per cent less than the quarterly facility average total
case mix score for the preceding calendar quarter.
(a) If the facility was subject to an
exception review for the preceding quarter in accordance with rule
5160-3-43.4 of the
Administrative Code, the assigned quarterly facility average total case mix
score shall be the score that is five per cent less than the score determined
by the exception review.
(b) If the
facility was assigned a quarterly facility average total case mix score for the
preceding calendar quarter, the assigned quarterly facility average total case
mix score shall be the score that is five per cent less than the score assigned
for the preceding quarter.
(D) ODM shall calculate a quarterly facility
average medicaid case mix score for all providers meeting the following
requirements:
(1) The provider's resident
assessment data submitted timely for that reporting quarter provided sufficient
information for classifying at least ninety per cent of records identified as
medicaid records into RUG non-default groups, or
(a) The provider's resident assessment data
submitted timely and corrected timely in accordance with the procedure outlined
in rule 5160-3-43.1 of the
Administrative Code for correcting incomplete or inaccurate information for
that reporting quarter, provided sufficient information for accurately
classifying at least ninety per cent of all residents into RUG non-default
groups; and
(b) There were no
errors that prevented ODM from verifying the records to be used in determining
the quarterly facility average medicaid case mix score.
(2) ODM shall identify a MDS 3.0 assessment
as a medicaid record if the MDS 3.0 assessment meets the following
requirements:
(a) The MDS 3.0 assessment is
not completed to meet the requirements for a medicare part A stay.
(b) The social security number (SSN) on the
MDS 3.0 assessment matches a SSN on the medicaid recipient master file (RMF)
(c) The assessment reference date
(ARD) on the MDS 3.0 assessment falls within the recipient's medicaid
eligibility span.
(3) The
quarterly facility average medicaid case mix score for providers that submitted
their MDS 3.0 data in compliance with paragraph (C)(1) of this rule shall be
calculated as follows:
(a) Medicaid resident
case mix scores for the quarter, including resident case mix scores in the RUG
default group, are added together; then
(b) The sum of medicaid resident case mix
scores is divided by the total number of medicaid residents.
(4) If a provider does not comply
with paragraph (D)(1) of this rule, ODM
may assign the NF a penalty
score. If assigned,
the penalty score
for the quarterly facility average medicaid case mix score shall be a score
that is five per cent less than the quarterly facility average medicaid case
mix score for the preceding calendar quarter.
(a) If the facility was subject to an
exception review for the preceding quarter in accordance with rule
5160-3-43.4 of the
Administrative Code, the assigned quarterly facility average medicaid case mix
score shall be the score that is five per cent less than the score determined
by the exception review.
(b) If the
facility was assigned a quarterly facility average medicaid case mix score for
the preceding calendar quarter, the assigned quarterly facility average
medicaid case mix score shall be the score that is five per cent less than the
score assigned for the preceding quarter.
(5) ODM
may use a
facility's assigned penalty score to calculate the semiannual facility average
medicaid case mix score.
(E) ODM shall calculate the semiannual
facility average medicaid case mix score as follows:
(1) The semiannual facility average medicaid
case mix score for the payment period beginning the first day of July for a
given fiscal year shall be the average of the quarterly facility average
medicaid case mix score from the preceding December and March reporting
quarters. If a facility does not have a quarterly facility average medicaid
case mix score for both the December and March reporting quarters, the median
annual facility average case mix score for the NF's peer group shall be
assigned as the semiannual facility average medicaid case mix score to
determine the direct care rate.
(2)
The semiannual facility average medicaid case mix score for the payment period
beginning the first day of January for a given fiscal year shall be the average
of the quarterly facility average medicaid case mix score from the preceding
June and September reporting quarters. If a facility does not have a quarterly
facility average medicaid case mix score for both the June and September
reporting quarters, the median annual facility average case mix score for the
NF's peer group shall be assigned as the semiannual facility average medicaid
case mix score to determine the direct care rate.
(F) ODM shall calculate the annual facility
average case mix score as follows:
(1) The
annual facility average case mix score shall be calculated only for facilities
with at least two quarterly facility average total case mix scores meeting the
requirements of paragraphs (C)(1) and (C)(2) of this rule. In addition, for any
score meeting the requirements of paragraphs (C)(1) and (C)(2) that was
adjusted, the adjusted score will be substituted according to the following
hierarchy:
(a) Adjusted quarterly facility
average total case mix scores established by a rate reconsideration decision
resulting from an exception review of resident assessment information conducted
before the effective date of the rate; or
(b) Adjusted quarterly facility average total
case mix scores as a result of exception review findings.
(2) If ODM assigned a facility a quarterly
facility average total case mix score in accordance with paragraph (C)(3) of
this rule, the assigned score will not be used to calculate the provider's
annual facility average case mix score.
(3) The qualifying case mix scores shall be
summed and divided by the total number of quarters of qualifying scores to
arrive at the annual facility average case mix score.
(G) For each provider that submits MDS 3.0
data in a given week, ODM shall send the "Case Mix Report" containing the
following four components:
(1) The "Provider
Detail Listing of Successfully Grouped Records," which identifies records that
were successfully grouped by ODM. The report will include all records received,
even if the records will not be used in the quarterly score
calculation.
(2) The "Critical
Error Summary," which identifies the records that will be assigned into the
default group unless they are corrected before the end of the reporting quarter
in accordance with rule
5160-3-43.1 of the
Administrative Code.
(3) The
"Provider Detail Listing of Records with Critical Errors," which provides
detail for each record listed on the "Critical Error Summary" identifying the
failed edits.
(4) The "Discharge
and Reentry Tracking Form Summary," which identifies all discharge assessments
and reentry tracking forms that were received by ODM.
(H) ODM shall provide two preliminary
"Calculation of Facility Case Mix Scores" reports. The first report will
reflect records submitted up to the quarterly filing date. The second report
will reflect records submitted up to approximately two weeks prior to the
quarterly corrections deadline. Both reports will include a calculation of the
quarterly facility average total case mix score and the quarterly facility
average medicaid case mix score. Providers may file corrections to the extent
permitted by rule
5160-3-43.1 of the
Administrative Code.
(I) After the
quarterly corrections deadline specified in rule
5160-3-43.1 of the
Administrative Code, ODM shall provide a final "Calculation of Facility Case
Mix Scores" report. The report will include a calculation of the quarterly
facility average total case mix score and the quarterly facility average
medicaid case mix score.
(J)
Following the determination of the two quarterly facility average medicaid case
mix scores used to calculate the semiannual facility average medicaid case mix
scores effective July first and January first of the fiscal year, ODM shall
provide a "Semiannual Medicaid Case Mix Score Calculation Report" to each
provider.
(K) Following the
calculation of the annual facility average case mix score, ODM shall provide an
"Annual Facility Average Case Mix Score Calculation Report" to each
provider.
