2006 Ohio Revised Code - 5111.20. Definitions.

§ 5111.20. Definitions.
 

As used in sections 5111.20 to 5111.34 of the Revised Code: 

(A) "Allowable costs" are those costs determined by the department of job and family services to be reasonable and do not include fines paid under sections 5111.35 to 5111.61 and section 5111.99 of the Revised Code. 

(B) "Ancillary and support costs" means all reasonable costs incurred by a nursing facility other than direct care costs or capital costs. "Ancillary and support costs" includes, but is not limited to, costs of activities, social services, pharmacy consultants, habilitation supervisors, qualified mental retardation professionals, program directors, medical and habilitation records, program supplies, incontinence supplies, food, enterals, dietary supplies and personnel, laundry, housekeeping, security, administration, medical equipment, utilities, liability insurance, bookkeeping, purchasing department, human resources, communications, travel, dues, license fees, subscriptions, home office costs not otherwise allocated, legal services, accounting services, minor equipment, maintenance and repairs, help-wanted advertising, informational advertising, start-up costs, organizational expenses, other interest, property insurance, employee training and staff development, employee benefits, payroll taxes, and workers' compensation premiums or costs for self-insurance claims and related costs as specified in rules adopted by the director of job and family services under section 5111.02 of the Revised Code, for personnel listed in this division. "Ancillary and support costs" also means the cost of equipment, including vehicles, acquired by operating lease executed before December 1, 1992, if the costs are reported as administrative and general costs on the facility's cost report for the cost reporting period ending December 31, 1992. 

(C) "Capital costs" means costs of ownership and, in the case of an intermediate care facility for the mentally retarded, costs of nonextensive renovation. 

(1) "Cost of ownership" means the actual expense incurred for all of the following: 

(a) Depreciation and interest on any capital assets that cost five hundred dollars or more per item, including the following: 

(i) Buildings; 

(ii) Building improvements that are not approved as nonextensive renovations under section 5111.251 [5111.25.1] of the Revised Code; 

(iii) Except as provided in division (B) of this section, equipment; 

(iv) In the case of an intermediate care facility for the mentally retarded, extensive renovations; 

(v) Transportation equipment. 

(b) Amortization and interest on land improvements and leasehold improvements; 

(c) Amortization of financing costs; 

(d) Except as provided in division (K) of this section, lease and rent of land, building, and equipment. 

The costs of capital assets of less than five hundred dollars per item may be considered capital costs in accordance with a provider's practice. 

(2) "Costs of nonextensive renovation" means the actual expense incurred by an intermediate care facility for the mentally retarded for depreciation or amortization and interest on renovations that are not extensive renovations. 

(D) "Capital lease" and "operating lease" shall be construed in accordance with generally accepted accounting principles. 

(E) "Case-mix score" means the measure determined under section 5111.232 [5111.23.2] of the Revised Code of the relative direct-care resources needed to provide care and habilitation to a resident of a nursing facility or intermediate care facility for the mentally retarded. 

(F) "Date of licensure," for a facility originally licensed as a nursing home under Chapter 3721. of the Revised Code, means the date specific beds were originally licensed as nursing home beds under that chapter, regardless of whether they were subsequently licensed as residential facility beds under section 5123.19 of the Revised Code. For a facility originally licensed as a residential facility under section 5123.19 of the Revised Code, "date of licensure" means the date specific beds were originally licensed as residential facility beds under that section. 

(1) If nursing home beds licensed under Chapter 3721. of the Revised Code or residential facility beds licensed under section 5123.19 of the Revised Code were not required by law to be licensed when they were originally used to provide nursing home or residential facility services, "date of licensure" means the date the beds first were used to provide nursing home or residential facility services, regardless of the date the present provider obtained licensure. 

(2) If a facility adds nursing home beds or residential facility beds or extensively renovates all or part of the facility after its original date of licensure, it will have a different date of licensure for the additional beds or extensively renovated portion of the facility, unless the beds are added in a space that was constructed at the same time as the previously licensed beds but was not licensed under Chapter 3721. or section 5123.19 of the Revised Code at that time. 

(G) "Desk-reviewed" means that costs as reported on a cost report submitted under section 5111.26 of the Revised Code have been subjected to a desk review under division (A) of section 5111.27 of the Revised Code and preliminarily determined to be allowable costs. 

(H) "Direct care costs" means all of the following: 

(1) (a) Costs for registered nurses, licensed practical nurses, and nurse aides employed by the facility; 

(b) Costs for direct care staff, administrative nursing staff, medical directors, respiratory therapists, and except as provided in division (H)(2) of this section, other persons holding degrees qualifying them to provide therapy; 

(c) Costs of purchased nursing services; 

(d) Costs of quality assurance; 

(e) Costs of training and staff development, employee benefits, payroll taxes, and workers' compensation premiums or costs for self-insurance claims and related costs as specified in rules adopted by the director of job and family services in accordance with Chapter 119. of the Revised Code, for personnel listed in divisions (H)(1)(a), (b), and (d) of this section; 

(f) Costs of consulting and management fees related to direct care; 

(g) Allocated direct care home office costs. 

(2) In addition to the costs specified in division (H)(1) of this section, for nursing facilities only, direct care costs include costs of habilitation staff (other than habilitation supervisors), medical supplies, emergency oxygen, habilitation supplies, and universal precautions supplies. 

(3) In addition to the costs specified in division (H)(1) of this section, for intermediate care facilities for the mentally retarded only, direct care costs include both of the following: 

(a) Costs for physical therapists and physical therapy assistants, occupational therapists and occupational therapy assistants, speech therapists, audiologists, habilitation staff (including habilitation supervisors), qualified mental retardation professionals, program directors, social services staff, activities staff, psychologists and psychology assistants, and social workers and counselors; 

(b) Costs of training and staff development, employee benefits, payroll taxes, and workers' compensation premiums or costs for self-insurance claims and related costs as specified in rules adopted under section 5111.02 of the Revised Code, for personnel listed in division (H)(3)(a) of this section. 

(4) Costs of other direct-care resources that are specified as direct care costs in rules adopted under section 5111.02 of the Revised Code. 

(I) "Fiscal year" means the fiscal year of this state, as specified in section 9.34 of the Revised Code. 

(J) "Franchise permit fee" means the fee imposed by sections 3721.50 to 3721.58 of the Revised Code. 

(K) "Indirect care costs" means all reasonable costs incurred by an intermediate care facility for the mentally retarded other than direct care costs, other protected costs, or capital costs. "Indirect care costs" includes but is not limited to costs of habilitation supplies, pharmacy consultants, medical and habilitation records, program supplies, incontinence supplies, food, enterals, dietary supplies and personnel, laundry, housekeeping, security, administration, liability insurance, bookkeeping, purchasing department, human resources, communications, travel, dues, license fees, subscriptions, home office costs not otherwise allocated, legal services, accounting services, minor equipment, maintenance and repairs, help-wanted advertising, informational advertising, start-up costs, organizational expenses, other interest, property insurance, employee training and staff development, employee benefits, payroll taxes, and workers' compensation premiums or costs for self-insurance claims and related costs as specified in rules adopted under section 5111.02 of the Revised Code, for personnel listed in this division. Notwithstanding division (C)(1) of this section, "indirect care costs" also means the cost of equipment, including vehicles, acquired by operating lease executed before December 1, 1992, if the costs are reported as administrative and general costs on the facility's cost report for the cost reporting period ending December 31, 1992. 

(L) "Inpatient days" means all days during which a resident, regardless of payment source, occupies a bed in a nursing facility or intermediate care facility for the mentally retarded that is included in the facility's certified capacity under Title XIX. Therapeutic or hospital leave days for which payment is made under section 5111.33 of the Revised Code are considered inpatient days proportionate to the percentage of the facility's per resident per day rate paid for those days. 

(M) "Intermediate care facility for the mentally retarded" means an intermediate care facility for the mentally retarded certified as in compliance with applicable standards for the medicaid program by the director of health in accordance with Title XIX. 

(N) "Maintenance and repair expenses" means, except as provided in division (BB)(2) of this section, expenditures that are necessary and proper to maintain an asset in a normally efficient working condition and that do not extend the useful life of the asset two years or more. "Maintenance and repair expenses" includes but is not limited to the cost of ordinary repairs such as painting and wallpapering. 

(O) "Medicaid days" means all days during which a resident who is a Medicaid recipient eligible for nursing facility services occupies a bed in a nursing facility that is included in the nursing facility's certified capacity under Title XIX. Therapeutic or hospital leave days for which payment is made under section 5111.33 of the Revised Code are considered Medicaid days proportionate to the percentage of the nursing facility's per resident per day rate paid for those days. 

(P) "Nursing facility" means a facility, or a distinct part of a facility, that is certified as a nursing facility by the director of health in accordance with Title XIX and is not an intermediate care facility for the mentally retarded. "Nursing facility" includes a facility, or a distinct part of a facility, that is certified as a nursing facility by the director of health in accordance with Title XIX and is certified as a skilled nursing facility by the director in accordance with Title XVIII. 

(Q) "Operator" means the person or government entity responsible for the daily operating and management decisions for a nursing facility or intermediate care facility for the mentally retarded. 

(R) "Other protected costs" means costs incurred by an intermediate care facility for the mentally retarded for medical supplies; real estate, franchise, and property taxes; natural gas, fuel oil, water, electricity, sewage, and refuse and hazardous medical waste collection; allocated other protected home office costs; and any additional costs defined as other protected costs in rules adopted under section 5111.02 of the Revised Code. 

(S) (1) "Owner" means any person or government entity that has at least five per cent ownership or interest, either directly, indirectly, or in any combination, in any of the following regarding a nursing facility or intermediate care facility for the mentally retarded: 

(a) The land on which the facility is located; 

(b) The structure in which the facility is located; 

(c) Any mortgage, contract for deed, or other obligation secured in whole or in part by the land or structure on or in which the facility is located; 

(d) Any lease or sublease of the land or structure on or in which the facility is located. 

(2) "Owner" does not mean a holder of a debenture or bond related to the nursing facility or intermediate care facility for the mentally retarded and purchased at public issue or a regulated lender that has made a loan related to the facility unless the holder or lender operates the facility directly or through a subsidiary. 

(T) "Patient" includes "resident." 

(U) Except as provided in divisions (U)(1) and (2) of this section, "per diem" means a nursing facility's or intermediate care facility for the mentally retarded's actual, allowable costs in a given cost center in a cost reporting period, divided by the facility's inpatient days for that cost reporting period. 

(1) When calculating indirect care costs for the purpose of establishing rates under section 5111.241 [5111.24.1] of the Revised Code, "per diem" means an intermediate care facility for the mentally retarded's actual, allowable indirect care costs in a cost reporting period divided by the greater of the facility's inpatient days for that period or the number of inpatient days the facility would have had during that period if its occupancy rate had been eighty-five per cent. 

(2) When calculating capital costs for the purpose of establishing rates under section 5111.251 [5111.25.1] of the Revised Code, "per diem" means a facility's actual, allowable capital costs in a cost reporting period divided by the greater of the facility's inpatient days for that period or the number of inpatient days the facility would have had during that period if its occupancy rate had been ninety-five per cent. 

(V) "Provider" means an operator with a provider agreement. 

(W) "Provider agreement" means a contract between the department of job and family services and the operator of a nursing facility or intermediate care facility for the mentally retarded for the provision of nursing facility services or intermediate care facility services for the mentally retarded under the medicaid program. 

(X) "Purchased nursing services" means services that are provided in a nursing facility by registered nurses, licensed practical nurses, or nurse aides who are not employees of the facility. 

(Y) "Reasonable" means that a cost is an actual cost that is appropriate and helpful to develop and maintain the operation of patient care facilities and activities, including normal standby costs, and that does not exceed what a prudent buyer pays for a given item or services. Reasonable costs may vary from provider to provider and from time to time for the same provider. 

(Z) "Related party" means an individual or organization that, to a significant extent, has common ownership with, is associated or affiliated with, has control of, or is controlled by, the provider. 

(1) An individual who is a relative of an owner is a related party. 

(2) Common ownership exists when an individual or individuals possess significant ownership or equity in both the provider and the other organization. Significant ownership or equity exists when an individual or individuals possess five per cent ownership or equity in both the provider and a supplier. Significant ownership or equity is presumed to exist when an individual or individuals possess ten per cent ownership or equity in both the provider and another organization from which the provider purchases or leases real property. 

(3) Control exists when an individual or organization has the power, directly or indirectly, to significantly influence or direct the actions or policies of an organization. 

(4) An individual or organization that supplies goods or services to a provider shall not be considered a related party if all of the following conditions are met: 

(a) The supplier is a separate bona fide organization. 

(b) A substantial part of the supplier's business activity of the type carried on with the provider is transacted with others than the provider and there is an open, competitive market for the types of goods or services the supplier furnishes. 

(c) The types of goods or services are commonly obtained by other nursing facilities or intermediate care facilities for the mentally retarded from outside organizations and are not a basic element of patient care ordinarily furnished directly to patients by the facilities. 

(d) The charge to the provider is in line with the charge for the goods or services in the open market and no more than the charge made under comparable circumstances to others by the supplier. 

(AA) "Relative of owner" means an individual who is related to an owner of a nursing facility or intermediate care facility for the mentally retarded by one of the following relationships: 

(1) Spouse; 

(2) Natural parent, child, or sibling; 

(3) Adopted parent, child, or sibling; 

(4) Stepparent, stepchild, stepbrother, or stepsister; 

(5) Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law; 

(6) Grandparent or grandchild; 

(7) Foster caregiver, foster child, foster brother, or foster sister. 

(BB) "Renovation" and "extensive renovation" mean: 

(1) Any betterment, improvement, or restoration of an intermediate care facility for the mentally retarded started before July 1, 1993, that meets the definition of a renovation or extensive renovation established in rules adopted by the director of job and family services in effect on December 22, 1992. 

(2) In the case of betterments, improvements, and restorations of intermediate care facilities for the mentally retarded started on or after July 1, 1993: 

(a) "Renovation" means the betterment, improvement, or restoration of an intermediate care facility for the mentally retarded beyond its current functional capacity through a structural change that costs at least five hundred dollars per bed. A renovation may include betterment, improvement, restoration, or replacement of assets that are affixed to the building and have a useful life of at least five years. A renovation may include costs that otherwise would be considered maintenance and repair expenses if they are an integral part of the structural change that makes up the renovation project. "Renovation" does not mean construction of additional space for beds that will be added to a facility's licensed or certified capacity. 

(b) "Extensive renovation" means a renovation that costs more than sixty-five per cent and no more than eighty-five per cent of the cost of constructing a new bed and that extends the useful life of the assets for at least ten years. 

For the purposes of division (BB)(2) of this section, the cost of constructing a new bed shall be considered to be forty thousand dollars, adjusted for the estimated rate of inflation from January 1, 1993, to the end of the calendar year during which the renovation is completed, using the consumer price index for shelter costs for all urban consumers for the north central region, as published by the United States bureau of labor statistics. 

The department of job and family services may treat a renovation that costs more than eighty-five per cent of the cost of constructing new beds as an extensive renovation if the department determines that the renovation is more prudent than construction of new beds. 

(CC) "Title XIX" means Title XIX of the "Social Security Act," 79 Stat. 286 (1965), 42 U.S.C. 1396, as amended. 

(DD) "Title XVIII" means Title XVIII of the "Social Security Act," 79 Stat. 286 (1965), 42 U.S.C. 1395, as amended. 
 

HISTORY: 138 v H 176 (Eff 7-1-80); 139 v S 550 (Eff 11-26-82); 141 v H 428 (Eff 12-23-86); 143 v H 672 (Eff 11-14-89); 143 v H 822 (Eff 12-13-90); 144 v H 904 (Eff 12-22-92); 145 v H 152 (Eff 7-1-93); 145 v H 715 (Eff 7-22-94); 146 v H 117 (Eff 6-30-95); 148 v H 471 (Eff 7-1-2000); 148 v H 403 (Eff 7-1-2000); 148 v H 448. Eff 10-5-2000; 150 v H 95, § 1, eff. 6-26-03; 151 v H 66, § 101.01, eff. 7-1-05; 151 v H 530, § 101.01, eff. 3-30-06.
 

The effective date is set by § 815.03 of 151 v H 530. 

The provisions of § 206.66.24 of 151 v H 66 read as follows: 

SECTION 206.66.24. TRANSITION METHODOLOGY FOR MEDICAID REIMBURSEMENT FOR NURSING FACILITIES. 

(A) There is hereby created the Nursing Facility Rate Transition Advisory Council. The Council shall consist of all of the following: 

(1) The Director of Job and Family Services or the Director's designee; 

(2) The Deputy Director of the Office of Ohio Health Plans of the Department of Job and Family Services or the Deputy Director's designee; 

(3) The Director of Health or the Director's designee; 

(4) One representative of Medicaid recipients residing in nursing facilities appointed by the Governor; 

(5) One representative of each of the following organizations appointed by the organization: 

(a) The Ohio Academy of Nursing Homes; 

(b) The Association of Ohio Philanthropic Homes and Housing for the Aging; 

(c) The Ohio Health Care Association. 

(B) Members of the Nursing Facility Rate Transition Advisory Council shall receive no compensation for serving on the Council. 

(C) The Director of Job and Family Services shall serve as chair of the Nursing Facility Rate Transition Advisory Council. 

(D) The Nursing Facility Rate Transition Advisory Council shall develop recommendations on the methodology to be used to phase in the nursing facility reimbursement formula established under sections 5111.20 to 5111.33 of the Revised Code. The Council shall prepare quarterly progress reports and, not later than nine months after the effective date of this section, a final report. The Council shall submit copies of the report to the Governor, the President and Minority Leader of the Senate, and the Speaker and Minority Leader of the House of Representatives. The Council shall cease to exist on the issuance of the final report. 

The provisions of § 206.66.23 of 151 v H 66 read as follows: 

SECTION 206.66.23. FISCAL YEAR 2007 MEDICAID REIMBURSEMENT SYSTEM FOR NURSING FACILITIES. 

(A) As used in this section: 

"Franchise permit fee" means the fee imposed by sections 3721.50 to 3721.58 of the Revised Code. 

"Nursing facility" and "provider" have the same meanings as in section 5111.20 of the Revised Code. 

"Nursing facility services" means nursing facility services covered by the Medicaid program that a nursing facility provides to a resident of the nursing facility who is a Medicaid recipient eligible for Medicaid-covered nursing facility services. 

(B) Except as provided in division (C) of this section, the provider of a nursing facility that has a valid Medicaid provider agreement on June 30, 2006, and a valid Medicaid provider agreement for fiscal year 2007 shall be paid, for nursing facility services the nursing facility provides during fiscal year 2007, the rate determined for the nursing facility under sections 5111.20 to 5111.33 of the Revised Code. 

(C) If the rate determined for a nursing facility under sections 5111.20 to 5111.33 of the Revised Code for nursing facility services provided during fiscal year 2007 is more than one hundred two per cent of the rate the provider is paid for nursing facility services the nursing facility provides on June 30, 2006, the Department of Job and Family Services shall reduce the nursing facility's fiscal year 2007 rate so that the rate is no more than one hundred two per cent of the nursing facility's rate for June 30, 2006. If the rate determined for a nursing facility under sections 5111.20 to 5111.33 of the Revised Code for nursing facility services provided during fiscal year 2007 is less than ninety-eight per cent of the rate the provider was paid for nursing facility services the nursing facility provides on June 30, 2006, the Department shall increase the nursing facility's fiscal year 2007 rate so that the rate is no less than ninety-eight per cent of the nursing facility's rate for June 30, 2006. 

(D) If the United States Centers for Medicare and Medicaid Services requires that the franchise permit fee be reduced or eliminated, the Department of Job and Family Services shall reduce the amount it pays providers of nursing facilities under this section as necessary to reflect the loss to the state of the revenue and federal financial participation generated from the franchise permit fee. 

(E) The Department of Job and Family Services shall follow this section in determining the rate to be paid to the provider of a nursing facility that has a valid Medicaid provider agreement on June 30, 2006, and a valid Medicaid provider agreement for fiscal year 2007 notwithstanding anything to the contrary in sections 5111.20 to 5111.33 of the Revised Code. 

The effective date is set by § 612.18 of 151 v H 66. 

The effective date is set by section 182 of H.B. 95 (150 v  - ). 

The provisions of § 232 of H.B. 95 (150 v  - ) read as follows: 

SECTION 232. Section 5111.20 of the Revised Code is presented in this act as a composite of the section as amended by both Sub. H.B. 403 and Sub. H.B. 448 of the 123rd General Assembly. The General Assembly, applying the principle stated in division (B) of section 152 of the Revised Code that amendments are to be harmonized if reasonably capable of simultaneous operation, finds that the composite is the resulting version of the section in effect prior to the effective date of the section as presented in this act. 

 

Effect of Amendments

151 v H 530, effective March 30, 2006, in (B), inserted "habilitation supervisors, qualified mental retardation professionals, program directors"; in (H)(1)(b), deleted "habilitation staff, qualified mental retardation professionals, program directors" following "medical directors" and "habilitation supervisors" following "respiratory therapists"; in (H)(2), inserted "costs of habilitation staff (other than habilitation supervisors)"; in (H)(3)(a), inserted "habilitation staff (including habilitation supervisors), qualified mental retardation professionals, program directors"; and corrected internal references. 

151 v H 66, effective July 1, 2005, rewrote the section. 

H.B. 95, Acts 2003, effective June 26, 2003, substituted "5111.34" for "5111.32" in the introductory paragraph; and deleted "consumer satisfaction survey fees paid under section 173.55 of the Revised Code" preceding "start-up costs" in (I).