Ohio Admin. Code 5123-7-01

Current through all regulations passed and filed through November 4, 2024

Section 5123-7-01 - Intermediate care facilities for individuals with intellectual disabilities - definitions

For the purposes of rules in Chapter 5123-7 of the Administrative Code, the following definitions apply:

(A) "Allowable costs" are those costs incurred for certified beds in an ICFIID as determined by the department to be reasonable, as defined in paragraph (K) of this rule, and do not include recoupments, fines, penalties, or interest paid in accordance with sections 5124.41, 5124.42, 5124.523, and 5124.99 of the Revised Code. Unless otherwise enumerated in Chapter 5123-7 of the Administrative Code, allowable costs are also determined in accordance with the following reference material, in the following priority:

(1) 42 C.F.R. Chapter IV, as in effect on the effective date of this rule;

(2) The centers for medicare and medicaid services provider reimbursement manual (publications 15-1 and 15-2, available at https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals.html); and

(3) Generally accepted accounting principles in accordance with standards prescribed by the "American Institute of Certified Public Accountants" (available at https://www.aicpa.org).

(B) "Date of licensure," for an ICFIID 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. For an ICFIID originally licensed as a residential facility, "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 or residential facility beds, or in the case of an ICFIID with more than eight beds or a nursing facility, it extensively renovates the facility after its original date of licensure, it will have a different date of licensure for the additional beds or for the extensively renovated facility, unless, in the case of the addition of beds, 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. The licensure date for additional beds or facilities which extensively renovate will be the date the beds are placed into service.

(C) "Department" means the Ohio department of developmental disabilities.

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

(E) "Inpatient days" means all days during which a resident, regardless of payment source, occupies a bed in an ICFIID that is included in the ICFIID's certified capacity under Title XIX of the Social Security Act, 49 stat. 620, 42 U.S.C.A. 301, as in effect on the effective date of this rule. Bed-hold days determined in accordance with rule 5123-7-08 of the Administrative Code are considered inpatient days proportionate to the percentage of the ICFIID's per resident per day rate paid for those days.

(F) "Intermediate care facility for individuals with intellectual disabilities" (or "ICFIID") has the same meaning as in section 5124.01 of the Revised Code.

(G) "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 an ICFIID.

(H) "Provider" means a person or government entity that operates an ICFIID under a provider agreement.

(I) "Provider agreement" means a contract between the Ohio department of medicaid and an operator of an ICFIID for the provision of ICFIID services under the medicaid program. The signature of the operator or the operator's authorized agent binds the operator to the terms of the agreement.

(J) "Qualified intellectual disability professional" has the same meaning as in 42 C.F.R. 483.430, as in effect on the effective date of this rule.

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

(L) "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 will 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 ICFIID from outside organizations and are not a basic element of resident care ordinarily furnished directly to residents by the ICFIID; and

(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.

(M) "Relative of an owner" means a person who is related to an owner of an ICFIID 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; or

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

(N) "Representative" means a person acting on behalf of an individual who is applying for or receiving medicaid. A representative may be a family member, guardian, attorney, hospital social worker, ICFIID social worker, or any other person chosen to act on the individual's behalf.

Ohio Admin. Code 5123-7-01

Effective: 7/1/2024
Five Year Review (FYR) Dates: 4/12/2024 and 07/01/2029
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5124.03
Rule Amplifies: 5123.04, 5124.01, 5124.03
Prior Effective Dates: 01/10/2013, 07/08/2018