START PREPARING NOW so you do not miss out on additional reimbursement.
Background
The Ohio biennium budget bill, House Bill (HB) 33 included a provision for a private room reimbursement incentive for skilled nursing facilities totaling $160M in FY2025. The reimbursement incentive is expected to equal $30 per day for category 1 private rooms and $20 per day for category 2 private rooms. Category 1 rooms are private rooms with a private bath while category 2 rooms are a private room with a shared (i.e., jack and jill bath). 
The private room category definitions in Ohio statute can be found here.
To receive the reimbursement incentive, providers will need to file an application with the Ohio Department of Medicaid (ODM) indicating the rooms that meet the criteria for the reimbursement incentive. There are some exclusions that apply; providers who are either Special Focus Facilities (SFF), SFF candidates or one-star facilities will not be able to apply for the private room reimbursement incentive.
Where we are today
ODM has yet to submit their state plan amendment to CMS for approval however, they have drafted a rule for the application and approval process. Even though ODM does not have CMS approval, the department plans to accept and approve applications to mitigate delays in private room incentive payments. ODM will hold approved applications for payment until CMS approval is received and the mandatory six-month wait time has passed.
The application for category 1 rooms only will open on January 2, 2024 at 8am. Since there is a cap on the amount that can be expended by the department for the private room incentive payments, these will be first-come, first-serve dollars. The department will accept applications until they have approved the maximum amount allowed, $160M. If funds are available after all category 1 applications are approved, applications for category 2 rooms will open on March 1, 2024.
Applications will be submitted by Medicaid Provider Number. Therefore, organizations with multiple facilities, with separate Medicaid Provider numbers, will need to file an application for each Medicaid number separately.
How to be ready for January 2, 2024
As mentioned, these are first-come, first-serve dollars and as such it is imperative that providers are ready to submit their application(s) as soon as the application tool opens. You will want to prepare ahead of time as much of the information as possible, especially those that will require significant time to accumulate.
While we are waiting for the ODM application instructions and access, a list of required information is contained in the emergency rule. We cannot underestimate the importance of having your information prepared ahead of time. The following items are facility-specific and expected to require significant time to gather and organize. ODM will be checking this data against Ohio Department of Health licensure data.
- 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 and category two private rooms as defined in ORC Section 5165.158.
- 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.
- Documentation evidencing the private room meets the following criteria in paragraph (C)(2) of section ORC Section 5165.158:
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- Private rooms that are in existence on July 1, 2023, in facilities where all of the licensed beds are in service on the application date;
- Private rooms created by surrendering licensed beds from its licensed capacity, or, if the facility does not hold a license, surrendering beds that have been certified by CMS. A nursing facility where the beds are owned by a county and the facility is operated by a person other than the county may satisfy 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 space to the nursing facility or renovating non-bedroom space, 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
- A nursing facility licensed after July 1, 2023, in which all licensed beds are in service on the application date or in which private rooms were created by surrendering licensed beds from its licensed capacity.
ODM has indicated they will release more details about the application process and criteria in the coming days and provided this email for questions NF_PrivateRoom@medicaid.ohio.gov.
If you have questions on the private room reimbursement incentive or any other reimbursement matter, please contact your HW Healthcare Advisor.
Senior Manager
helen.weeber@hwco.cpa
