Medicaid rates for Ohio nursing facilities were recalculated on January 1, 2020, to reflect:

  • Semi-annual case-mix adjustment using the average of the June 30, 2019, and September 30, 2019, Medicaid case-mix scores.
  • Removal of the 2.4% SNF market basket price increase implemented on July 18, 2019, and the addition of a new ORC 5165.26 quality payment. The new quality payment utilizes the pot of money from the 2.4% market basket price increase and redistributes it based upon points earned.

Ohio skilled nursing facility Medicaid rates have undergone many changes between January 1, 2019, and January 1, 2020, resulting in 4 different rates versus the usual 2. The budget bill (HB 166) for State Fiscal Year (SFY) 2020-2021 was not finalized in time for July 1, 2019 rate changes; therefore, June 30, 2019 rates were paid during the interim budget period through July 17, 2019.  On July 18, 2019, HB 166 rates were implemented which included a 2.4% SNF Market Basket price increase, semi-annual case-mix adjustment and SFY 2020 quality payment under the existing 7 point system.  Rates were reduced to remove market basket price increase from tax & $16.44 components when SFY 2020-2021 budget became effective on October 17, 2019.  Statewide averages for all 4 rate periods are as follows:


ORC 5165.26 New Quality Points System

As discussed above, a new quality points system was implemented on January 1, 2020. The statewide average new quality payment was $5.32 (13.31 points at $.40 per point).   Facilities that experienced a change of provider (CHOP) or opened between January 2, 2018, and December 31, 2019, were excluded from the quality payment.  This affected 162 (17%) providers that would have earned an average of 13.65 points for $5.46 in quality.  This Ohio Department of Medicaid (ODM) position adds new complexity to determination of the optimal timing for a CHOP.  Contact us for more details and assistance if you are considering acquiring a facility.

The following charts provide more details on average points and number of facilities earning points:


Effective July 1, 2020, an occupancy provision is added to the ORC 5165.26 new quality payment system.   Facilities that are less than 80% occupied and earn less than 15 quality points will receive no quality payment from July 1, 2020, to June 30, 2021.  Occupancy will be based on 2019 days using December 31, 2019, licensed beds.  Quality points will be determined using the 4-quarter 2019 weighted average.  Based upon the most recent data available, we estimate that over 200 (24%) facilities are at risk for no quality payment.   Contact us if you would like to know if you are at risk.

Accounts Receivable Aging (AR) Review

As discussed above, nursing facilities have now had three Medicaid rate changes in the past 6 months:  July 2019, October 2019 and January 2020.  The rate changes in July and October, in particular, were problematic and caused revenue cycle/billing issues since there were two different rates in each month.  ODM issued billing instructions for each of these months in order to have your claims processed or re-processed to reimburse your facility correctly.  As you complete AR Aging Reviews there may be small balances or contractual adjustments remaining for Medicaid or MyCare Medicaid Room and Board claims for these months. Determine if the claims you submitted were adjusted appropriately and cash applied correctly or if further claim review is necessary.  Thankfully, the January 2020 rates were received in time to update your system prior to billing for these dates of service.  You should review your remittances carefully to be sure that you have been reimbursed at the correct rate by Medicaid and the MyCare plans.  As always, please contact our Revenue Cycle team if you have questions or need assistance.

Review your rate package for accuracy

Rate packages are available in MITS. It is important that you review these calculations closely for possible errors, as there is a tight timeframe for filing rate reconsideration requests. Contact us if you need assistance.

As always, the updated rates will impact payments from both traditional Medicaid and MyCare Ohio Medicaid. Though ODM is putting additional pressure on the MyCare plans to accurately update the rates, be sure to review your MyCare payments carefully, as the MyCare plans have had significant issues in the past.

How can we help?

Please contact us for assistance with any of the following:

  • Reviewing your January 1, 2020, Medicaid rate
  • Filing a rate reconsideration
  • Detailed Medicaid rate history, case-mix, and quality analysis
  • More details on the HB 166 Medicaid rate changes and new quality system
  • Want to know if you are “at-risk” for receiving no quality payment at 7/1/2020
  • Determining optimal timing for acquiring a facility
  • Benchmarking expenses, census and staffing against selected competitors, as well as county, peer group and statewide averages
  • Any other reimbursement, revenue cycle, accounting or tax needs


Paula Z. Reape, CPA, LNHA