Report of the



Report of the

Nursing Facility Reimbursement Study Council

Representative Shawn Webster, Chairman

July 21, 2004

Introduction

House Bill 95 of the 125th General Assembly charged the Nursing Facility Reimbursement Study Council (NFRSC) with studying the Medicaid reimbursement system for nursing facilities and issuing a report by July 30, 2004. The report is directed to the Governor, the Speaker of the House, and the President of the Senate. After that date, the NFRSC is required to continue its work and periodically report its activities, findings, and recommendations.

In addition to Chairman Webster, the NFRSC is composed of Director Tom Hayes of the Ohio Department of Job and Family Services (ODJFS), Barb Edwards of ODJFS, Greg Moody of the Governor’s Office, Anne Harnish of the Ohio Department of Health (ODH), Director Joan Lawrence of the Ohio Department of Aging (ODA), Representatives Bill Seitz and Dixie Allen, Senators Randy Gardner, Lynn Wachtmann, and Eric Fingerhut, consumer representative Mary Butler, Mike Scharfenberger and Linda Black-Kurek of the Ohio Health Care Association, John Alfano and Mike Compton of the Association of Ohio Philanthropic Homes, Housing, and Services for the Aging, and Norm Dreyer and Bert Cummins of the Ohio Academy of Nursing Homes. Ken Kovach of the Kovach Company facilitated NFRSC meetings.

The NFRSC met 13 times since July 2003. To aid in the council’s deliberations, Chairman Webster formed four work groups: the Reform Funding Base/Creative Work Group chaired by Representative Seitz, the Regulatory Reform Work Group chaired by Director Lawrence, the Formula Work Group chaired by Representative Webster, and the Eligibility Work Group chaired by Representative Allen.

These work groups developed recommendations within their specific areas. Their recommendations, as adopted or modified by the full NFRSC, are set forth below.

Reform Funding Base/Creative Work Group

Participants

Representative Bill Seitz, Chair

Leslie Akers, Taxation

John Alfano, AOPHA

Carla Brumby, ODH

Norm Dreyer, OANH

Sharon Evanich, ODA

Rich Frederick, Insurance

Gloria Gardner, Taxation

Tom Hayes, ODJFS

Christine Kenney, ODH

Michael Scharfenberger, OHCA

Jamie Young, OHCA

Ken Kovach, Facilitator

 

Conversion of Nursing Home Space

To Alternative Uses and Bed Banking

Recommendation:

C-1 Reduce excess capacity by decreasing the number of Medicaid-certified beds in Ohio by allowing Medicaid-certified nursing homes to convert unused space for alternative uses and to bank beds to serve the local community.

• By amending current State law and administrative rule, nursing homes can accept and deliver services to other Ohioans who are currently underserved.

o Possible alternative uses may include temporary shelter for children in which no treatment is provided, emergency shelter for children with mental health issues in which services would be provided, foster care, detoxification facility for teens, and adult day care.

o Other possibilities include battered women’s shelters and housing for elderly, non-violent community control (halfway house) persons with medical needs.

o Many alternative uses represent existing programs that are currently being funded by other state and local sources but which represent areas of unmet need. In these instances, nursing homes may offer more suitable environments than currently exist for the delivery of these services and thus enable the local community to be better served.

• This recommendation would require amending existing laws and rules to provide for the following:

o When banking beds and converting nursing home space to alternative uses, the provider must notify ODH Licensure/Certification. ODH will notify ODA and the State Long-Term Care Ombudsman of any requests it receives and allow them to offer input on ODH’s determination to approve the request.

o The banked beds would remain licensed while in the bank. Banked beds would not be included in calculating the facility’s occupancy rate. The provider would be required to pay license renewal fees and all other applicable fees on banked beds. ODH would approve bringing beds back into active licensed status without re-inspection if a facility has a good survey history.

o Any time beds are banked and the space converted to an alternative use, the capital cost and any other costs associated with that space would not be reported on the nursing facility’s cost report.

o This arrangement would only apply to beds banked after the effective date of the implementing legislation.

o The provider would obtain approval for the proposed alternative use from ODH to ensure the personal safety of nursing home residents, including the submission of floor plans and a written description of the intended alternative use. The facility must also obtain building code approval for the alternative use.

o When banking beds and converting nursing home space to alternative uses, the provider must maintain accommodations for individuals that do not require nursing home services or personal care services in a separate and discrete part or unit from the nursing home residents.

o Require providers to maintain separate and discrete use of dining and recreational areas for all alternative services, except adult day care.[1] Any space over the square footage required by licensure for the number of nursing home beds not banked may be used for alternatives, provided that space is separate and discrete from the nursing home population. Sharing of space between a nursing home and a child care or pre-school operation would be permitted, provided there is some amount of dedicated recreational space for the children.

o The facility must maintain separate nursing and direct care staff in nursing home and alternative service areas for each shift.

o The facility may share maintenance, laundry, housekeeping, and kitchen services. The cost of this space must be allocated for times not used for the nursing home and omitted from the cost report.

o ORC 3721.07 (G) would need to be changed to permit the type of alternative uses of nursing homes discussed above. The current language of that section of the law does not allow the facility to accept or treat outpatients, etc., as noted below:

“Except in approved alternate use space, the home does not accept or treat outpatients, except upon the written orders of a physician licensed in this state, maternity cases, boarding children, and does not house transient guests, other than participants in an adult day-care program, for 24 hours or less.”

• ODJFS and ODH, working with the nursing home groups, should publicize to all nursing homes with significant vacancy rates the kinds of alternative uses that may be approved, the payment source for these alternative uses, and the process for securing alternative use approval.

• This program for facilitating alternative use of underutilized nursing home space does not affect existing practices and procedures for temporarily removing nursing home beds from service.

Long-Term Care Insurance

Recommendations:

C-2 Significantly increase the penetration of long-term care insurance in the Ohio marketplace by developing a state-endorsed, private-sector LTC insurance plan and expanding participation in the LTC insurance programs for state employees and for veterans and their family members.

• By increasing the pool of Ohioans who have purchased LTC insurance, we reduce future reliance on Medicaid as a funding source, encourage purchase of policies when they are very affordable at younger ages, and reduce the incidence of estate planning to become Medicaid-eligible (together with the expenses to the State of estate recovery).

• The state should develop a long-term care insurance offering, endorsed/sponsored by Ohio, but paid for by participating public and private-sector employees, at a price reflecting the State’s rate bargaining power as evidenced by the favorable rates of the existing State LTC plan that is offered to State employees.

o Ohio will need to locate at least three LTC insurers (Best-rated A or better) willing to commit to a LTC policy offering that has the same rates and same terms.

o The likely volume of covered lives requires more carriers than the single provider - - Aetna- - now used by Ohio for the State employee program.

o Employers will be less likely to participate if multiple insurers offer multiple different rates and terms.

o Ohio will serve as the aggregator for the LTC carriers, using the Best Rx model for prescription drugs as a rough example of how the State uses its purchasing power to obtain favorable purchasing terms for private-sector employees.

o The State should design the contours of the “Ohio Basic LTC Policy.” Salient variables include:

▪ Establishing standards for rating practices, rate schedule increases, inflation protection, contingent benefits upon lapse, nonforfeiture benefits (typically, employee receives back upon lapse either what he paid in premiums or thirty times the daily benefit), and elimination period.[2]

▪ Requiring that the policy provide benefits for either facility-based or in-home care.

▪ Requiring that the policy be “portable” (moves from employer to employer, and out of state if the employee moves out of state).

▪ Requiring a minimum length of coverage of three years.

o Legislation (similar to Ohio’s Best Rx) may need to be enacted to permit the state to offer this policy to non-state employees.

• The state should significantly increase participation rates in the State’s existing LTC insurance plan through a strong marketing program and through requiring participation by State employees, as legally allowed.

o The mandated purchase of LTC insurance by State employees should be a collective bargaining priority for the State in its negotiations with represented employees, but is not a legal issue with respect to non-represented employees.

• Because the public’s understanding of the need for LTC insurance is poor, there will have to be a vigorous and well-funded effort to do all of the following:

o Promote Ohio’s existing LTC offering to State employees (currently only 900 of 60,000 employees purchase it);

o Promote to Ohio veterans and their extended families a similar, attractively priced LTC offering that is available through the federal government to all active and retired veterans and their extended families; and

o Promote the new State program to private employers.

• One or more state agencies (DAS? Insurance?) should be designated the lead agency to do all of the following:

4 Design the “Ohio Basic LTC Policy” parameters.

o Select the carriers that will participate in the program.

o Work with the Adjutant General’s office to promote the benefits of participation in the federal veterans/families LTC insurance program.

o Work with Aetna to better market the existing state employee LTC insurance program to state employees, so as to increase participation.

o Promote the federal government’s LTC insurance offering to Ohio veterans and National Guard members, and their families.

o Work with those responsible for state employee collective bargaining strategy to determine how best to require state employee participation in the state’s LTC insurance program.

o Work with the selected carriers, Ohio Chamber of Commerce, the County Commissioners Association, the Ohio Township Association, the Ohio Municipal League, and other employer associations to “roll out” the Ohio basic LTC policy to all public and private-sector employees in Ohio.

C-3 Ohio should pressure Congress to eliminate the federal ban on LTC partnership programs. These programs allow LTC insurance buyers to become eligible for Medicaid once the insurance is exhausted without further asset divestiture, and without estate recovery (income eligibility requirements remain, however).

President Bush’s 2005 budget proposal included a plan to eliminate the 1993 ban on LTC partnership programs that was enacted as part of OBRA.

Senator Larry Craig has introduced federal legislation to eliminate the ban. Prior to 1994, Indiana, Connecticut, California, and New York adopted LTC partnership proposals, and through December 2000, 94,525 LTC policies were issued through these programs in those four states.[3] Three other states (Illinois, Massachusetts and Washington) offer partnership programs that involve either asset protection during the purchaser’s life (with full estate recovery) or no asset protection but protection against state estate recovery.[4]

• Ohio should evaluate whether to pursue a partnership program that would make a person automatically eligible for Medicaid-covered long-term care services (disregarding both the asset and income tests) at the end of the person’s LTC insurance coverage, if the person purchases a policy for a specified period of time that would be greater than three years.

C-4 Ohio should urge Congress to include LTC insurance premium expenses as eligible expenses in Federal §125 Cafeteria plans (Flexible Spending Accounts).

• This would allow payment of these premiums with pre-tax (above the line) dollars, and improve the tax benefits of LTC insurance.

If this ever happens, Ohio would then consider repealing the above-the-line deduction it now offers for unreimbursed long-term health care premiums.

No-Lift Program

Recommendation:

C-5 Amend rules or law to create and fund a Long-Term Care Loan Fund (LTCLF) designed to provide interest-free loans for implementing “No-Lift” programs in nursing facilities.

• Loan funds would be used to purchase sit-to-stand floor lifts, ceiling lifts, other lifts, and “fast” electric beds.

• Loan funds would also cover education and training to support providers in implementing a facility policy of no manual lifting of residents.

• Funding for the program would be placed in a time-limited loan fund within the Ohio Bureau of Workers’ Compensation.

o BWC annual premiums should substantially decrease.

o BWC annual claims should decrease by up to 90%.

o ODJFS should realize savings in Medicaid costs as a result of lower facility costs.

• The purpose of this loan fund would be to:

o Reduce injuries to staff and residents;

o Contribute to a decrease in workers compensation premiums;

o Eventually result in a reduction of Medicaid expenditures due to lower costs for workers compensation, which is reported on the cost report;

o Treat residents with dignity.

• Possible funding sources for the no-lift fund:

o Seek statutory authority, if needed, for BWC to create a loan fund of a minimum of 4 million dollars. Nursing homes could apply for a one-time, time limited, no interest loan, which could be utilized for the purpose of installing the no-lift programs. The loan amount would be reported on the facility cost report in a manner prescribed by the Ohio Administrative Code and generally accepted accounting standards. We would be able to draw federal match on the depreciation of the equipment. The loan would be repayable over a period of five (5) years. BWC would establish a prioritization system for awarding these loans.

o Appropriate $2 million from the Resident Protection Fund for FY 06/07 and FY07/08, depending on the availability of funds, until all nursing facilities, which need and choose to, have installed no-lift programs.

o Urge BWC to approve nursing homes for safety grants.

• The Ohio Board of Nursing should work with the nursing schools in Ohio to ensure that “no-lift” technology is taught in the nursing schools, so employees are familiar with the technology through in-servicing.

Regulatory Reform Work Group

Participants

Ohio Academy of Nursing Homes

Ohio Health Care Association

AOPHA

Ohio Board of Nursing

Licensed Practical Nurse Association of Ohio, Inc.

Ohio Nurses Association

Ohio Department of Aging

State Long-Term Care Ombudsman

Ohio Department of Health

Ohio Department of Job and Family Services

Ohio Olmstead Task Force

Summary

The Regulatory Reform Subcommittee met eight times to finalize the following recommendations. All participants had the opportunity to propose regulatory changes. The group decided not to consider changes that would receive public attention in the 2006 five-year rule review, which will commence in 2005, facilitated by ODH.

At least two changes, often sought, already have been made by the Public Health Council of ODH. These are the rules for Dining Assistants, single purpose workers for feeding nursing home residents (effective 5-17-04) and the rule broadening the health care settings in which a nurse aide may work to remain on the Nurse Aide Registry (scheduled for adoption 6-10-04).

Alternative Survey Process

Recommendation:

R-1 Advocate for state flexibility in the federal nursing home survey process that allows greater oversight and monitoring of nursing homes with a history of noncompliance and less extensive oversight of consistently compliant nursing homes.

• Seek change in federal law that would either:

o Allow states flexibility in the federal certification survey process for both Medicaid and Medicare certified facilities; or

o At a minimum, authorize the federal government to allow states to conduct pilot alternative survey projects for both Medicaid and Medicare facilities. The federal law may need to provide for additional funding to cover pilot projects.

• Possible budgetary and funding impact due to the decrease in the number of standard surveys required annually and the unpredictability of number of on-site surveys needed for noncompliant nursing homes. The federal level may limit the number of monitoring or follow-up visits allowed per budget cycle. Additional state funding may be needed.

• Formulate a coalition of regulators, payors, providers, consumers, advocates, and researchers to re-design the regulatory process, using as a basis the modified survey protocol developed in 1998 by an ad hoc committee of interested parties.

Criminal Background Check Standards

Recommendation:

R-2 Amend the criminal records check law to establish objective standards (such as forgiveness periods) for hiring an individual with criminal convictions and to eliminate personal character standards adopted by rule by ODH and other agencies.

• BCII would continue to be the sole agency responsible for processing the record requests to assure consistency in process across the State.

• Rather than establishing some sort of an appeal process for older or lesser infractions, forgiveness periods should be included in the statute and rules with respect to “less serious” crimes.

• Eliminate requirement for State agencies to promulgate rules establishing personal character standards.

• A special group of interested parties, including individuals with criminal law expertise, should be established (legislatively mandated) to review the current Ohio criminal records law. This committee would:

o Review the list of crimes that disqualify an individual from being hired for direct care positions to determine which crimes may be subject to forgiveness periods.

o Review Legislative Service Commission Memorandum R-125-2947 to learn how other states are dealing with this issue. Concerns were raised that the general nomenclature of the listed offenses may capture a variety of criminal action and that an in-depth review of the crimes would be required before any recommendations could be made as to eliminating certain disqualifying offenses from the list.

o Determine the length of the forgiveness period, for example, certain crimes committed more than 10, 15, or 20 years prior to date of application for employment.

o Review the current personal character standards to determine what, if any, of those standards should be included in the statutory revisions as objective exceptions to the bar from employment.

Criminal Background Check Process

Recommendation:

R-3 Reduce actual turnaround time for receiving results of criminal background reports, thereby eliminating the need to fire a conditional employee due to late receipt of a criminal records report.

• Providers could share the cost of purchasing and maintaining the Web Check technology and obtain quicker results, generally available within 2 business days.

• Alternatively, providers could make use of publicly available technology by identifying equipment listed on the BCII website.

• Add language to the statute that would allow providers to retain conditional employees longer than 30 days if there are quality problems with fingerprints on rolled cards.

• Develop methods for querying BCII databases in order to obtain information by provider type.

o For example, the request form for a records check requires the requestor to indicate which statute authorizes the request.

o Generating a report of how many record requests under a given statutory section (provider type) were completed within 30 days or how many were returned for illegible fingerprints would assist policy makers in determining if any changes are needed in the criminal records check process.

• Provide training for individuals who assist with obtaining fingerprints on how to obtain legible prints or recognize when prints may be illegible and need to be redone prior to initial submission.

Minimum Data Set

Recommendation:

R-4 Eliminate all areas of Section S of the Minimum Data Set (MDS), except item S-12, and allow the use of the shorter MDS form (MPAF) for quarterly assessments to help decrease the paperwork burden in nursing homes while maintaining compliance with federal requirements and continuing to collect necessary data for reimbursement and quality indicators/quality measures.

• Whenever normally allowed by state and federal requirements, nursing facilities may use the shorter Resident Assessment Instrument/MPAF form (Medicare PPS Assessment Form) for quarterly assessments.

• Facilities will additionally submit along with each MPAF Quarterly Assessment, the Background Information at Admission Form in order to include the resident’s entry date.

• Elimination of Section S and utilization of the shorter form will decrease documentation time while preserving the collection of necessary data.

• ODJFS would need to change rule 5101:3-3-40, OAC, to eliminate Section S and allow for the form change for quarterly assessments. These rules will necessarily mirror related federal language (42 CFR 483.20(6)(5)/F276).

Medication Technicians

Recommendation:

R-5 Pilot-test the use of medication technicians in nursing homes and licensed residential care facilities that provide medication administration.

• This would provide an alternative approach to the current requirement that all medications be administered only by licensed nurses (or physicians, dentists) in Ohio nursing homes.

• By allowing the administration of routine medications by appropriately trained and supervised medication technicians, professional nurses would have more time to assess residents and perform more complex nursing tasks.

• This approach would also help address the healthcare workforce shortage, improve staff retention, and create career ladder opportunities for nursing assistants.

• Establish the following parameters for this program:

o Board of Nursing agreement to regulate the practice of medication technicians.

o Training requirements and curriculum, including annual recertification.

o Stakeholder agreement on standards (e.g., types of medications and routes permitted to be administered by medication technicians, prerequisite completion of nurse aide competency and evaluation program).

o Criteria for and selection of pilot facilities.

o Pilot time line and evaluation criteria (e.g., quality indicators, cost analysis, workforce impact indicators, and resident satisfaction) focused on decision points for statewide implementation.

• NOTE: Participants in the discussion of this recommendation included:

o Ohio Department of Aging

o Office of the State LTC Ombudsman

o Ohio Department of Health

o Ohio Board of Nursing (neutral position on this recommendation but would want to be the regulatory body)

o Ohio Health Care Association

o Ohio Academy of Nursing Homes

o Association of Ohio Philanthropic Homes, Housing, and Services for the Aging

o Ohio Nurses Association (opposed to the recommendation)

o LPN Association of Ohio (opposed to the recommendation)

o Separately discussed with Ohio Assisted Living Association

Supplemental Staffing Agencies

Recommendation:

R-6 Establish licensing regulations for supplemental nursing service agencies (Nursing Pool) to ensure that these agencies and their staff comply with all pertinent requirements relating to the health screening and other qualifications of personnel employed in health care facilities, at least to the minimum requirements of the health care providers to which they furnish staff.

• Licensing requirements should include, but not be limited to:

o Employee criminal background checks

o Employee reference checks

o Employee health and qualifications

o Nurse aide registry checks

o Orientation and training for employees’ projected job assignment situations

o Quality improvement programs

o Workers compensation

o Liability insurance

• Require the supplemental staffing agency to document that each temporary employee provided to health care facilities currently meets the minimum licensing, training, and continuing education standards for the position in which the employee will be working.

• Establish a system for reporting, investigating, and resolving complaints against a supplemental staffing agency or its employees.

• Establish an enforcement system that would include, at a minimum, civil money penalties for non-compliance.

Formula Work Group

Introduction

The Ohio General Assembly charged the NFRSC with evaluating the existing nursing facility reimbursement methodology and making recommendations of any necessary changes. The NFRSC created the Formula Work Group to consider alternatives and make recommendations to the NFRSC as to how reimbursement should be structured in the future. The Formula Work Group did not undertake any analysis of the adequacy of current rates.

The Formula Work Group consists of the following participants: Representative Shawn Webster, Chair; Senator Randy Gardner; Brian Perera, Senate Finance Director; Barbara Edwards, Harry Saxe, Julie Evers, Trish Martin, Tracy Williams, Franklin Blair II and Bob Tornow, ODJFS; Joan Lawrence and Roland Hornbostel, ODA; Anne Harnish and Barb Petering, ODH; Linda Black-Kurek, Peter Van Runkle, and Barry Jamieson, OHCA; Mike Compton and Bill Kutschbach, AOPHA, and Bert Cummins and Roger King, OANH. Maggie Lewis facilitated group discussions, and Jamie Kocinski from Representative Webster’s office and Stephanie Franz and Peter Voderberg, LSC interns, participated in the meetings. Mary Butler, consumer representative, attended some of the earlier meetings.

The work group met 21 times between February 12 and July 20, 2004. The conversations in the Nursing Facility Reimbursement Study Council have resulted in significant strides being made in developing a proposal for reform of the nursing facility reimbursement formula. The detailed proposals, potential areas of agreement, and key differences are summarized in Attachment 1. A report of the work group’s progress is set forth below.

Goals

The work group established the following goals for reform of the nursing home reimbursement formula:

Goal 1: The reimbursement system should assure access to quality care for disabled and elderly Ohioans who choose and who need nursing facility care and provide adequate funds to enable efficiently operated long-term care facilities to purchase the necessary goods and services which will enable a resident to achieve and maintain the highest practicable physical, mental and psycho-social well-being. The payment system should include a component that links payment to quality of services provided based upon agreed-to measures.

Goal 2: The reimbursement system should provide a reasonable payment that enables a sufficient number of efficiently operating providers to deliver services that meet Medicaid consumer needs while complying with state and federal statutes, regulations and standards.

Goal 3: The payment system should seek to contain or to slow the rate of growth of Medicaid expenditures.

Goal 4: The reimbursement system should result in predictable rates and expenditures, and should strive for administrative simplicity.

Progress Report

Overall, the members of the work group agree that the group has made substantial progress toward developing significant, long-term reform of the nursing home reimbursement formula. Both the administrative agencies and the provider groups, collectively, have made comprehensive, detailed reform proposals intended to contain costs. The work group members have discussed these proposals extensively and are working toward resolving the differences between them. Detail on these issues is provided below and in Attachment 1.

The issues, however, are extremely complex, and the work group members agree that further discussions are needed to resolve remaining differences and refine the proposals in this report. This process will proceed consistent with the recommendations in this report (except as specifically delineated through minority reports or other notations of disagreement) and consistent with the state fiscal year 2006-2007 budget process. All parties are committed to building on the tremendous progress to date and to sustaining consensus among the parties to the greatest extent possible. To that end, the work group members have established a goal of completing a consensus payment system reform proposal by December 31, 2004, or sooner if possible.

The following paragraphs outline the progress the work group has made on the various categories of issues. The “agreements” listed below are tentative only, because they could be affected by decisions made on other areas of the formula. The formula truly is an integrated whole and can only be fully evaluated and decided upon in its entirety.

Cost Center Realignment

Current System:

• Currently the reimbursement methodology is based on four cost centers – direct care costs, indirect care costs, other protected costs, and capital costs.

Progress:

Direct Care and Ancillary Services

• The agencies and the provider groups have tentatively agreed to divide the direct care cost center into two components. A case mix adjusted component will include, at a minimum, RN wages, LPN wages, state tested nurse aide wages, respiratory therapist wages and purchased nursing expenses.

• A second direct care component called Ancillary Services will not be case mix adjusted. Ancillary Services will include, at a minimum, dietary expenses and routine medical supplies.

• Other accounts that will be included in either Direct Care or Ancillary Services include Medical Director, Director of Nursing, RN Charge Nurse, LPN Charge Nurse, Activity Director, Activity Staff, Recreational Therapist, Program Director, Habilitation Supervisor, Habilitation Staff, Psychologist, Psychology Assistant, Social Work/Counseling, Social Services/Pastoral Care, Quality Assurance, Consulting and Management Fees – Direct Care, Other Direct Care and Home Office Costs – Direct Care. Nurse Aide training expenses will also be included in either Direct Care or Ancillary Services.

• In most instances, payroll taxes and fringe benefits will be placed in the same cost center as the related wages. However, a proposal to place workers compensation costs for direct care staff in the Other Protected cost center has been made by the provider groups.

Administration/Support Services

• The state agencies and provider groups have tentatively agreed that dietary expenses will be moved from Administration/Support Services to the Ancillary Services Cost Center.

• The provider groups have proposed moving workers’ compensation costs for staff in this cost center and insurance expenses from Administration/Support Services to the Other Protected Cost Center.

• Conversely, the agencies have proposed to move franchise fee, minor medical equipment, utilities, home office costs – other protected and any payroll taxes related to those expenses to Administration/Support Services. The state agencies also proposed continuing to include insurance and workers compensation expense in this cost center.

• There is tentative agreement that all other accounts currently included in the indirect care cost center (e.g., habilitation supplies, medical records, pharmaceutical consultant, incontinence supplies, personal care supplies, program supplies, administrator, other administrative personnel, consulting and management fees – indirect care, office and administrative supplies, communications, security, travel, laundry and housekeeping, accounting, legal services, data services, informational advertising, repairs and maintenance) be placed in the Administrative/Support Services cost center.

Capital

• There is tentative agreement that depreciation, interest, and lease/rent expense will remain in the capital cost center.

• The agencies have proposed including property taxes in the capital cost center. The provider associations have proposed to move government mandated life safety code related expenditures to the other protected cost center.

Other Protected

• The agencies have proposed eliminating the Other Protected cost center and moving those costs to cost centers with ceilings. The agencies proposed to move utility costs, medical supplies, and the franchise permit fee to the support services cost center and to move property taxes to the capital cost center.

• The provider groups have proposed maintaining the other protected cost center and adding insurance, workers’ compensation, and government mandated life safety code related expenditures.

Peer Groups

Current System:

• Peer groups are intended to recognize regional differences in cost experience within the state when establishing ceilings for direct care costs and indirect care costs.

• The current system includes 4 peer groups (Cincinnati, Cleveland, MSA (Metropolitan Statistical Area), and Other).

• The ODJFS is required by rule to conduct a statistical study of the existing peer groups as the result of changes in metropolitan statistical areas as defined by the United States Office of Management and Budget.

Progress:

• The agencies and the associations have agreed to retain peer grouping in a revised rate-setting methodology and have recognized that the peer groups will be different from those used today. The impact of these changes tends to be redistributive among facilities.

• The agencies proposed to use three peer groups (Cincinnati, MSA, and Other).

• The provider associations proposed to maintain the existing four peer groups as they are currently constituted, except for moving 5 counties from the “Other” peer group into the MSA group.

Direct Care and Ancillary Services

Current System:

• The Direct Care cost center represents the cost of hands-on patient care. In the existing system, this cost center includes costs for direct care staff, administrative nursing staff, direct care consulting and management fees, direct care home office expense, medical directors, social services, activities, psychologists and psychology aides, respiratory therapists and habilitation staff. Payroll taxes and employee benefits related to direct care staff wages are included in the direct care cost center.

• Under the current system, rates for the direct care cost center are case-mix adjusted. In other words, the formula takes into account each facility’s case mix (acuity) when determining how much of its direct care costs are to be reimbursed. This is done by calculating a cost per case mix unit (CPCMU) for each facility and by establishing the cost center ceiling using cost per case mix unit.

• The current ceiling for direct care is set at 123.78% of the median cost per case-mix unit for facilities in the peer group within three standard deviations of the mean.

• In determining allowable costs against which the ceiling will be applied, there are separate disallowance calculations for purchased nursing costs and out of facility meals costs. (The latter disallowance currently applies to the indirect care cost center.)

• Facilities’ rates are adjusted quarterly for changes in their case-mix scores (acuity).

Progress:

• The agencies and the provider associations agree that Ohio’s reimbursement system for direct care costs should remain a cost-based, case-mix adjusted system.

• The agencies and associations have also agreed to divide costs into a case mix adjusted (direct care) component and a second component (ancillary services) that is expected to have cost based reimbursement but will not be case-mix adjusted. As noted above under Cost Center Realignment, discussions are ongoing regarding the compositions of these cost centers.

• The agencies and the provider associations have tentatively agreed to eliminate the purchased nursing disallowance and the out of facility meals disallowance.

• The agencies and the provider associations have also tentatively agreed to include only facilities within one standard deviation (+/-) of the mean in the ceiling calculation.

• The agencies and the provider associations tentatively agree to rebase direct care and ancillary services per diems and ceilings annually.

• The agencies propose to use a blend of the ECI (Employment Cost Index) and CPI (Consumer Price Index) for the direct-care inflation factor while the provider groups propose to continue to use the ECI. The parties agree that reconfiguring the cost centers as discussed above requires re-evaluation of the appropriate inflation factors for each.

• The agencies and provider associations have agreed to use the same case mix scores for mid-year adjustments and annual CPCMU calculations.

• The agencies propose to adjust for acuity changes semi-annually, while the provider groups propose to continue quarterly adjustments for acuity.

• The agencies propose setting the ceiling at the 75th percentile within each peer group while the provider associations propose setting the ceiling at 116% of the median cost per case mix unit using the group of facilities within one standard deviation of the peer group mean. A possible compromise that has been discussed is to establish ceilings using a percentile the first year and then convert the ceilings to a percentage over the mean or median for subsequent years. The percentage would be the same for all peer groups.

Administration/Support Services

Current System:

• This cost center is currently known as the indirect care cost center and includes dietary costs, administrative costs, laundry and housekeeping, habilitation supplies, and medical records. Payroll taxes and employee benefits related to wages included in the indirect care cost center are included in this cost center. It is important that there be a sufficient mix of costs in this cost center to maximize the provider’s ability to make decisions based on business needs.

• The ceiling for indirect care is set at 112.5% of the inflated median cost of facilities in the peer group within three standard deviations of the mean.

• The ceiling for indirect care is rebased every other year.

• There is a separate sub-ceiling for administrator salaries.

• An imputed occupancy factor of 85% is used in calculating rates.

Progress:

• The agencies and the provider associations have tentatively agreed to work on development of a market pricing system that appropriately controls cost and the rate of growth. This price would be subject to periodic updates.

• The agencies and the provider associations have tentatively agreed to include only facilities within one standard deviation (+/-) of the mean in any market pricing system that is developed.

• The agencies and the provider association have tentatively agreed to use a 90% imputed occupancy factor in any market pricing system that is developed.

• The agencies and the provider associations have tentatively agreed that administrator and owner/family salary ceilings could be eliminated within a system that otherwise contains cost.

• The agencies proposed to use a blended (ECI/CPI) inflation factor while the provider associations are proposing to continue to use the CPI as the inflation factor.

• The parties are continuing discussions on the appropriate level for the price for this cost center and the appropriate mechanism for updating the price.

Capital

Current System:

• The capital cost center includes depreciation expense, lease expense, and interest expense.

• Cost of ownership (or lease) expenses are reimbursed at 88.65%; renovation costs are reimbursed at 85%.

• An imputed occupancy factor of 95% is applied.

• An efficiency incentive and return on equity payment are available for facilities that qualify.

• There is a maximum ceiling on capital reimbursement of $19.66 (inflated annually).

• On sale of a facility, depreciation recapture is imposed, but is phased out for facilities under the same ownership for more than 5 years.

Progress:

• The agencies propose to further investigate the concept of a fair rental value capital reimbursement methodology.

• The agencies and the provider associations have tentatively agreed to eliminate return on equity and the cost of ownership efficiency incentive.

• The agencies and the provider associations have tentatively agreed to use 100% imputed occupancy in establishing capital rates.

• The agencies proposed to set the ceiling for capital at the median cost per day for the peer group, using 100% imputed occupancy. The agencies proposed to rebase this ceiling every ten years.

• The provider associations propose to utilize the current ceiling, but to limit inflation of the ceiling to 75% of the current index in the years following the two-year freeze.

• The agencies have proposed combining cost of ownership, renovations, and property taxes and using 100% of the costs in calculating the per diem.

• The provider associations have proposed continuing to reimburse cost of ownership at 88.65% of costs and renovations at 85% of costs. In the provider association proposal, property taxes are included in the other protected cost center.

• The agencies proposed to eliminate the current phase-out of depreciation recapture. The providers proposed to maintain the current system for recapture.

Other Protected

Current System:

• The Other Protected Cost Center includes medical supplies, property taxes and utilities in the current system.

• The rate for the Other Protected Cost Center is calculated using actual inpatient days and is not subject to any ceiling.

Progress:

• The agencies have proposed the elimination of the Other Protected Cost Center by moving the expenses to cost centers with ceilings and, often, imputed occupancy.

• The provider associations have proposed expanding the other protected cost center to include workers’ compensation costs for all categories of staff, insurance expenses, and government mandated life safety code related expenditures. The rate would continue to be calculated using actual inpatient days and would not be subject to any ceiling.

Quality Incentive

Current System:

• Under the current system, incentive payments are available in various parts of the formula to support desired provider behavior.

• There are efficiency incentives in indirect care and capital, a return on equity payment, and a $2.25 quality add-on.

Progress:

• The agencies and the provider groups have tentatively agreed to eliminate the existing efficiency incentives, along with return on equity and the quality add-on

• The agencies and the provider groups have tentatively agreed to adopt a quality incentive plan to reward desirable behaviors and/or business practices.

• The agencies and provider groups are continuing to work on a quality incentive based on multiple accountability measures, similar to the Iowa system.

• The agencies and provider associations have tentatively agreed to calibrate the system to produce a specified (but as yet undetermined) average percentage incentive payment.

• The agencies and associations have tentatively agreed on several measures to be included in the quality incentive program and are continuing to evaluate several others. Measures to be included are compliance with certification requirements (two levels), nursing staff hours, resident and family satisfaction, employee retention (by peer group), and Medicaid utilization. Measures being evaluated for possible inclusion are facility case-mix, the CMS quality measures, returning residents to community, facility occupancy, service to minority populations, and continuity of ownership/lease.

Franchise Permit Fee

Current System:

• The current system has provisions including the franchise permit fee mandated by state law in the calculation of the per diem rate.

• These provisions divide the fee into a $1.00 component reimbursed through the other protected cost center and a $3.30 component reimbursed via an add-on.

• In both instances, the franchise fee expense is divided by inpatient days.

Progress:

• The agencies and the associations recognize the need to continue a franchise permit fee.

• The agencies and the associations agree that the franchise permit fee will be reflected in the reimbursement methodology.

• The agencies proposed to combine the $1.00 portion of the fee and the $3.30 portion of the fee and move the total franchise fee to the Administration/Support Services Cost Center (which utilizes an imputed occupancy factor).

• The provider associations proposed to pay the entire $4.30 as an add-on (outside any cost centers) calculated using inpatient days.

Certificate of Need

Current System:

• Ohio has a long-standing CON law that applies to long-term care facilities.

• Ohio also has had a moratorium on new long-term care beds in place since 1993 that limits new construction/opening of beds to replacement of existing beds within the same county.

Progress:

• The agencies and the provider associations recognize that decisions relating to the CON program are integrally related to the structure of the capital reimbursement system. Discussion of potential changes to the CON program in the context of overall payment system reform are ongoing.

• The agencies proposed to eliminate certificate of need with appropriate reform of the reimbursement methodology.

• The associations proposed to retain CON and the moratorium.

CHOP Rates

Current System:

• A CHOP is a change of operator/provider (most often due to a sale or lease) and may require the calculation of a rate for the entering provider outside the standard rate-setting methodology.

• A facility that undergoes a CHOP that involves unrelated parties or an inter-generational transfer may be entitled to an increase in its capital rate that is limited by a step-up calculation or subject to a maximum rent limitation provided in rule. Otherwise, its rate is based on the previous provider’s rate.

• Facilities that undergo a CHOP must file a three-month cost report, and their rates are adjusted based on that report.

Progress:

• The agencies and the provider associations recognize the need to allow CHOPs as an exit strategy while eliminating any resulting inflated payment rates.

• The agencies and the provider associations agree that the methodology used to establish CHOP rates will be driven by the methodology developed for standard rates.

• The agencies and the provider associations tentatively agree that an initial rate will be established for a facility that undergoes a CHOP using a specified formula and then a three month cost report will be used to recalculate CHOP rates after the initial period of operation.

• The agencies and associations have agreed that providers will be required to file the 3-month cost report within 60 days after the end of the 3 month period and that a cost report will be considered “cleared” if it is filed electronically with no fatal errors.

New Facility Rates

Current System:

• The current system includes provisions for establishing rates for new facilities (replacements of existing facilities) outside of the normal formula because these facilities do not have their own cost experience.

• These provisions specify how initial rates are to be calculated and require the rates to be adjusted based on a cost report covering the facility’s first three months of operation.

Progress:

• The agencies and the provider associations agree that the methodology used to establish new facility rates will be driven by the methodology developed for standard rates.

• The agencies and the provider associations tentatively agree that an initial rate will be established for a new facility using a specified formula and then a three month cost report will be used to recalculate new facility rates after the first three months of operation.

• The agencies and associations have agreed that providers will be required to file the 3-month cost report within 60 days after the end of the 3 month period and that a cost report will be considered “cleared” if it is filed electronically with no fatal errors.

Mid-Year Rate Adjustments

Current System:

• Providers’ rates can be adjusted during the course of a fiscal year for acuity (case-mix) and also for other circumstances.

• Those circumstances include rate calculation errors, extreme hardship or extreme circumstances, and government mandates.

Progress:

• The agencies and the provider associations have tentatively agreed to eliminate rate adjustments for extreme hardship and extreme circumstances. These rate adjustments will be replaced by rate adjustments related to “Acts of God” (e.g., tornado, flood, fire).

• The agencies and the provider associations have agreed to maintain rate adjustments for government mandates and to work to clarify the definition of government mandate.

Owner Salary Ceilings

Current System:

• In addition to the cost center ceilings, the current system includes special ceilings on reimbursement of salaries for owners who work in the business and corporate officers.

• These ceilings are recalculated annually based on the average of non-owner salaries and state compensation for selected positions for corporate officer salary ceilings.

Progress:

• The agencies and the provider associations have tentatively agreed that owner salary ceilings and corporate officer salary ceilings could be eliminated within a system that otherwise contains cost.

Relative Cost of Proposals

Current System:

• Using calendar year 2002 cost data, the current system yielded a statewide average per diem rate of $163.45 before application of the rate cap of $156.68 that was mandated by statute for FY04.

• Using a database that excludes facilities with recent provider agreement changes, the statewide average per diem using CY02 costs was $161.78.

• Using the same database that excludes facilities with recent provider agreement changes, the statewide average per diem after application of the legislatively mandated rate cap was $155.08 using CY02 costs.

Progress:

• Using this same database and CY02 costs, the agencies calculated the statewide average per diem rate for their proposal at $154.52.

• Using this same database and CY02 costs, the provider associations calculated the statewide average per diem rate for their proposal at $160.10.

• The parties are continuing their analysis of the two proposals and potential compromise positions using the CY02 data and the recently available CY03 cost report database.

• The parties also are evaluating the impact of the various approaches described above on cost growth in future years.

Transition

Progress:

• The agencies and associations agree that appropriate time is needed between completing development of the new payment system and its implementation so providers can understand the new system and modify their spending behavior accordingly and state government can revise its internal systems to pay the new rates.

• The agencies and the associations have established a goal to complete the work on a revised reimbursement methodology by December 31, 2004 for implementation by July 1, 2006 (for state fiscal year 2007 rates).

• The agencies and the associations recognize the need to develop a transition reimbursement system for implementation by July 1, 2005 (for state fiscal year 2006 rates).

Vehicle for Implementation

Current System:

• Currently, almost all significant parts of the reimbursement formula are specified by statute in the Ohio Revised Code.

• ODJFS has authority to adopt implementing rules, but not to change the statutory requirements.

Proposals:

• The agencies proposed that the new reimbursement methodology will be contained in Administrative Code provisions rather than the Ohio Revised Code.

• The provider associations proposed that the new reimbursement methodology will be contained in the Ohio Revised Code.

Annual Environmental Scan

For the purpose of tracking trends in the long-term care system (both institutional and non-institutional settings) as they relate to nursing facility reimbursement, the Department of Aging shall convene annually representatives of nursing home providers, consumers, the Ohio General Assembly, and the Departments of JFS, Aging, Health, MRDD, and MH. The assembled members of this group shall survey key benchmarks of the status of long-term care delivery. Indicators shall be presented longitudinally, if possible, in order to identify established and emerging trends. Measures shall be agreed to by members of the group; however, the following shall be included at a minimum:

1. Rates and expenditures compared to budgetary targets

2. Indicators of consumer demand (unmet need)

3. Demographics

4. Federal law changes

5. Changes in acuity

6. Changes in occupancy

7. Length of stay

8. Assisted living occupancy

9. Quality indicators

10. Admission patterns

11. Changes in residents’ payer mix

12. Availability of community-based long term care

13. Proportion of new Medicaid funding spent on HCBS vs. NF services

14. Home and community-based services cost, utilization, and enrollment

15. Cost per eligible NF resident – per diem

16. Provider cost changes – volatility (Workers’ Compensation, liability insurance, etc.)

As part of this evaluation, it is recommended that Ohio contract with the Employee Benefit Research Institute to conduct a Future Retirement Income Assessment for the state. The purpose of the project is to provide an approximation of the percentage of state residents who will have sufficient retirement income to cover health and housing expenses. The model is refined, projecting three levels of health status, and employing data from private pension systems and Social Security. The state would need to contribute statistical-level data on state pension plans at an approximate cost of $20,000. This assessment will assist the Ohio policy-makers in understanding the future challenges to long-term care financing and permit the state and employers to anticipate solutions where policy challenges are identified.

After reviewing all of this information, the group performing the environmental scan will recommend any changes in the reimbursement formula deemed necessary, along with any other measures relating to the long-term care system in general.

Next Steps

As summarized above, great progress has been made in working toward a revised reimbursement methodology for nursing facilities. However, significant differences in philosophy and funding levels remain. Both the state agencies and the provider associations are committed to continue to work toward resolution of those issues. Conversations are continuing with the next meeting scheduled for late August. In the meantime, the agencies and the provider associations are working on data analysis to better understand the fiscal impacts of the different proposals and policy research. Understanding the implications of the proposals on spending in the initial years of operations and on the rate of growth in spending over time is essential if compromise is to be reached.

Eligibility Work Group

Participants

Representative Dixie Allen, Chair

Mary Butler, Ohio Olmstead Task Force

Kenn Daily, Ohio Health Care Association

Matt Hobbs, Ohio Department of Aging

Judy Patterson, Ohio Department of Aging

Ann Shane, Ohio Department of Job & Family Services

Jane Taylor, Ohio Association of Area Agencies on Aging

Jamie Young, Ohio Health Care Association

Maria Mone, Facilitator

Asset Divestiture & Estate Recovery

Recommendations:

E-1 The Ohio Commission to Reform Medicaid should examine the state’s current nursing home eligibility determination and estate recovery standards and procedures to ascertain the prevalence of Medicaid estate planning and to recommend measures to address any problems in this area.

• No Ohio studies have examined the prevalence of Medicaid estate planning.

• Brian Burwell, author of Medicaid Eligibility Policy and Asset Transfers: Does Any of This Make Sense?, suggests the following sources for studying estate planning:

o Results from the Income Eligibility Verification System (IEVS), which compares income reported to the IRS with records from Social Security, Worker’s Compensation, and state tax agencies;

o A stand alone computer matching study with IRS data;

o A survey of new Medicaid enrollees;

o A survey of Medicaid eligibility workers;

o A study of the home equity of Medicaid nursing home recipients and the potential for Medicaid cost recovery;

o A study of the asset transfers among married recipients in nursing homes; and

o Qualitative policy analysis of Medicaid estate planning.

• Stephen Moses, Center for Long-Term Care Financing, is a nationally recognized expert in this area and has conducted studies for several states. See for a listing.

E-2 The Legislature should evaluate the definition of "estate," for purposes of potentially expanding the Medicaid estate recovery program to include any property in which an individual had any legal title or interest at the time of death, including assets passed outside probate.

E-3 The legislature should strengthen Ohio law to allow the Attorney General and local prosecutors to take a more aggressive approach to stopping family members, guardians, or responsible parties from diverting resources of Medicaid-eligible nursing home residents that should be used to pay for their services. These actions prevent facilities from collecting the Medicaid-approved reimbursement for services provided.

Eligibility Standards & Process

Recommendations:

E-4 ODJFS should evaluate increasing the asset limit to $10,000 from $1,500 for people applying for Medicaid home and community-based waiver services. The evaluation should study the pros and cons of changing this requirement, including the fiscal impact.

• Most aged, blind and disabled people who qualify for Medicaid have incomes that are below the Federal poverty level.

• Presently, when living in the community, if a major expense occurs, the person with $1,500 in assets may not have the funds to pay for it. Raising the cap may allow more people to stay in the community longer and maintain their homes and automobiles.

• Federal law allows states to use more liberal income and resource methodologies to determine Medicaid eligibility if they so choose.

E-5 It would not be practical to reduce state spending through tightening of the Medicaid financial eligibility standards. Ohio’s financial eligibility standards are comparatively restrictive. All personal income, except for $40 per month, must be used to pay for the cost of care. There is a retained asset limit of $1,500, and the mandatory sale of the personal home after six months of care. The Ohio legislature should consider the following:

• The need for long-term care can be devastating to a family. The average cost of care in an Ohio nursing home is roughly $4,500 per month and rising, and the possibility of the need for long-term care is real.

• Other than private resources and long term care insurance, frail elderly Ohioans are dependent upon Medicaid, a state-federal partnership providing health care to the poor.

• Medicaid is a welfare program with resources that are being stretched to the limit. Other states, through recent initiatives, and the federal government, through recent legislation and the Centers for Medicaid and Medicare Services (CMS), are imposing more and more restrictive eligibility rules.

• According to state figures, the total public and private expenditures for nursing home care in 2003 were $4.5 billion, of which Medicaid paid approximately 60%.

E-6 The Ohio Access Cabinet should study the feasibility of annually re-determining the level of care for each Medicaid nursing facility resident.

• There has been some speculation whether there are individuals currently residing in nursing facilities that no longer meet the level of care criteria. Over time, their health may have improved to the point they would no longer be eligible for Medicaid payment.

• Individuals receive a level of care review for the purposes of initiating Medicaid vendor payment to the nursing facility. Many people receive this review when they are admitted to the facility and others may receive it once other payment sources, such as Medicare, other insurance, or private funds run out.

• Current law contains no requirement for residents to have their levels of care reviewed on a regular basis. Once a person receives a level of care determination, for the most part, it is not reviewed again.

E-7 The Ohio Access Cabinet should evaluate the effectiveness of the pre-admission screening and resident review process and the ability to request federal approval to eliminate the process.

• Current federal and state law and rules would need to be reviewed and a study conducted to evaluate whether the pre-admission screening and resident review process meets its goal.

Public Education

Recommendation:

E-8 ODA should determine if there are additional methods of providing education to the public regarding all available long-term care services/options.

• An enhanced public education component at ODA would include providing information directly to individuals and/or their family members who may be in need of long-term care services.

• There would also be an enhanced education program that would target providing information to professionals such as doctors and hospitals that come into contact with long-term care consumers.

Acknowledgement

Beginning in late July, the Council met on a monthly basis, exploring the issues surrounding Nursing Facility Reimbursement. Those who presented at the July, August and September meetings included: Dr. Robert Applebaum from the Scripps Gerontology Center at Miami University with an overview of long term care; Donna Folkemer with the National Conference of State Legislatures with a presentation on national policy issues and reforms from other states in nursing facility reimbursement; and David Miller, Certified Long Term Care Insurance Specialist, with an overview of Long Term Care Insurance in Ohio. The October meeting of the Council was a panel discussion. Mr. Shawn White, Ms. Keshia Dickson, and Ms. Emily LoBue, from the Cuyahoga County Department of Senior and Adult Services, gave recommendations as to how to cut costs and improve the efficiency of Medicaid benefits to Nursing Homes. Roland Hornbostel of the Ohio Department of Aging presented an introductory overview of Ohio’s preadmission review of nursing facility applicants; Karen Vrtunski with the Western Reserve Area Agency on Aging provided a detailed description of the Pre-Admission Resident Review process; Mike Schroeder of the Ohio Department of Mental Health reviewed the PASRR process, as utilized for individuals with serious mental illness; and Jeff Davis of the Ohio Department of Mental Retardation and Developmental Disabilities described his department’s role in the PASRR process. Other presenters included Donald Chapin, Elder Law Attorney and Mr. Jay Julian, of ZA Consulting, who spoke on the County Commissioners Association of Pennsylvania Program for alternative community care.

The study portion of the council was complete by December. Work groups were formed at the January 21 meeting to investigate eligibility, regulatory reform, and potential ways of altering the funding base for long term care. Another work group was formed later to examine and consider structural changes to the reimbursement formula. Additional presentations to the council, as requested by various work groups included: Medicaid Eligibility for Ohio’s Aged, Blind, and Disabled, by Ann Shane of ODJFS; An Overview of Long Term Care Insurance by Rich Frederick of the Ohio Department of Insurance; and Certificate of Need by Christine Kenney of ODH. In addition, Jennifer Carlson from the Ohio Commission to Reform Medicaid spoke to the Nursing Facility Reimbursement Study Council regarding her Commission’s efforts.

Over the course of the council’s proceedings, many people have commended me as chairman for the significant progress that has been made in addressing the various long term care issues. The final worth of our proceedings will be measured by how many of the council’s recommendations will be incorporated in the next budget bill. Short of that, I do believe that the dialogue has been advanced to a point of real change and can serve as a solid foundation from which the Ohio Commission to Reform Medicaid can build.

I want to take this opportunity to recognize and thank two particular individuals that were instrumental to the council’s success. They are Maggie Lewis, Associate Director for the Ohio Commission on Dispute Resolution and Conflict Management and Jamie Kocinski, my Administrative Aide.

Maggie not only provided our study council facilitator, Ken Kovach, but early on at my request coached, advised, and educated me as to how to chair a council that had a history of being unable to achieve consensus. Her follow through by facilitating the formula subcommittee truly made the difference.

Jamie practically single-handedly directed all communications and scheduling. The fact that the council met monthly over a period of nearly a year in addition to being divided into four subcommittees attests to the challenge that she most ably handled.

Collectively, I want to thank those individuals who responded to my request to help Jamie and me throughout the subcommittee process and the writing of the report. I am assured those individuals know who they are without my naming them, but I must give special kudos to Pete Van Runkle.

I also believe that the informality of the process fostered an interactive relationship of interested parties with the council and provided assistance that often times is excluded in a strict committee process.

Sincerely,

[pic]

Shawn Webster

Chairman, Joint Nursing Facilities

Reimbursement Study Council

State Representative

Ohio House of Representatives

53rd District

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[1] The subgroup has a difference of opinion over whether the “separate and discrete” requirement can be satisfied by adhering to a schedule that gives each population a separate, but adequate, time in these facilities. The Chairman believes that this common-sense proposition should be enacted/permitted.

[2] Many of these standards were established in legislation enacted in 2001 by the Minnesota legislature, according to a July 2003 NCSL State Legislative Report “Budgeting for long term care: spending limited dollars more wisely” (Volume 28, No. 9). See also “The Five Choices of LTC Insurance”, by David M. Miller, 121 N. Market Street, Wooster, Ohio 44691 (330-262-6611).

[3] See “The Partnership Post,” Joint Report of California Health Services Partnership for Long Term Care, Connecticut Partnership for Long Term Care, Indiana Long Term Care Insurance Program, and NYS Partnership for Long Term Care.

[4] Id.

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