12/07/2023

ODM Releases Guidance on Nursing Facility Private Room Reimbursement

The 2024-2025 biennium budget authorized Ohio Department of Medicaid (ODM), upon Centers for Medicare & Medicaid Services (CMS) approval, to reimburse for private rooms at qualifying nursing facilities for non-medical necessity reasons. This week, ODM published guidance outlining the application process and criteria for those interested in applying for this new opportunity. As a reminder, LeadingAge Ohio will be hosting ODM officials on its All-Member Webinar on Tuesday, December 19 at 11:30AM. 

Overview:

House Bill 33 authorized $160 million over the biennium for Medicaid private room payments. Payments will be made based on two categories of rooms:

• Category One: $30 per day for private rooms with a private bath (toilet and sink).
• Category Two: $20 per day for private rooms with a bath shared with one other person.

Beginning January 2, 2024, Ohio Medicaid will begin accepting applications for approval of Category One private rooms only. Applications for Category Two private rooms begin March 1, 2024.

Applications will be accepted on a first come, first serve basis using the criteria described below.

Criteria:

Private room reimbursements will only be available to nursing facilities with:

• Private rooms existing as of July 1, 2023, in facilities where all licensed beds are in service on the application date.
• Private rooms created by surrendering licensed beds from the facility’s licensed capacity, or, if the facility does not hold a license, surrendering beds that have been certified by CMS. Facilities in which beds are owned by a county and operated by an entity other than the county can meet this requirement by removing beds from service.

NOTE: surrendering beds needs to be complete before an application can be approved, but beds do not need to be surrendered at the time of application.

• Private rooms created by adding or renovating space to the nursing facility, without increasing the total licensed bed capacity.

NOTE: renovating space needs to be complete before an application can be approved, but renovations do not need to be complete at the time of application.

• Private rooms in facilities licensed after July 1, 2023, and created by surrendering licensed beds from their licensed capacity.

Private Room Reimbursement Application:

The application process for Category One private rooms will begin at 8 a.m. Eastern time on Tuesday, January 2. ODM will use the same survey tool used to survey Ohio nursing homes earlier this year on freezing their case mix or continuing to use the optional state assessment.

Applications must be submitted by Medicaid provider number. Any multisite provider interested in participating will need to submit separate applications for each nursing facility.

• Applications must include all of the following at submission:
• List of all nursing facility rooms and their corresponding number of beds, designating the rooms for which private room incentive payment approval is requested and identifying which rooms are Category One private rooms as defined in section 5165.158 of the Revised Code (as noted above, Category Two applications will not be accepted until March 1, 2024).
• Floor plan of the entire nursing facility which identifies and shows the location of each private room with the designated room number and designated bathroom. Arrows should indicate the path between each resident room and the bathroom and each resident room and the hallway.
• Attestation in the form and manner prescribed by the department that the information submitted by the facility is accurate and truthful.
• The list of rooms and floor plan will be able to be uploaded with the application, and ODM will check this data against Ohio Department of Health licensure data.

Private room incentive payments will be disbursed no sooner than April 1, 2024, following approval by CMS and ODM. Further, only approved applications will receive incentive payments.

In the coming days, Ohio Medicaid will release more details about the application process and criteria. In the meantime, to address immediate questions, please email us at NF_PrivateRoom@medicaid.ohio.gov.