Department of Health & Human Services Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 Chicago, Illinois 60601-5519

CMTS

CENTERS for MEDICARE & MEDICAID SERVICES

JUN = 1 2010

Tracy Plouck, Deputy Director

Office of Ohio Health Plans

Ohio Department of Job and Family Services P.O. Box 182709

50 West Town Street, Suite 400

Columbus, Ohio 43218

RE: TN 09-021

Dear Ms. Plouck:

Enclosed for your records is an approved copy of the following State Plan Amendment:

Transmittal #09-021

Please contact Heather

An amendment to update five State Plan pages to reflect the new resource limit for Medicare Savings Plans, as amended by MIPPA section 112 and to exempt Medicare cost sharing from Medicaid estate recovery for six categories of dual eligibles with dates of service on or after January 1, 2010

Brown-Palsgrove, of my _ staff, at (312) 886-2417 or

heather.brown-palsgrove@cms.hhs.gov if you have any questions.

Enclosure

cc: Daphne Kackloudis Becky Jackson

Associate Regional Administrator Division of Medicaid and Children’s Health Operations

Attachment A to CMS 179 TN 09-021

Block 7

The total estimated impact of the MIPPA changes reflected in TN 09-021 is broken down by MIPPA section as follows.

MIPPA §112

The estimated annual total impact of increased premiums and other cost-sharing due to the increased resource limits under MIPPA section 112 is $68,885.96. This increases the annual federal cost by $50,610. For FFY 2010, this means an increase of $37,958. For FFY 2011, this increases the annual federal cost by $50,610.

Translated into thousands per the instructions on the CMS 179, the fiscal impacts related to MIPPA section 112 are:

a. FFY 2010 $38

b. FFY 2011 $51

MIPPA §115

The estimated annual total impact of unrecovered assets due to MIPPA section 115 is $115,100 per year. This reduces the annual federal share of recovery by $84,564. For FFY 2010, the reduced recovery is estimated to be $63,423. For FFY 2011, the reduced recovery is estimated to be $84,564.

Translated into thousands per the instructions on the CMS 179, the fiscal impacts related to MIPPA section 112 are:

a. FFY 2010 $63

b. FFY 2011 $85

Introduction Page 53a-2

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE OF OHIO

CITATION LIENS AND ADJUSTMENTS OR RECOVERIES

1917(b)(1)(B) (3) For any individual who received medical assistance at age 55 or older, adjustments or recoveries of payments are made from the individual's estate for nursing facility services, ICF/MR services, home and community based services, and related hospital and prescription drug services rendered after attainment of the age of fifty-five.

X__ In addition to adjustment or recovery of payments for services listed above, payments are adjusted or recovered for other services under the State plan as listed below, but not including medical assistance for Medicare cost sharing (i.e., Part A & B premiums, deductibles, coinsurance and co-payments) for the following categories of dual eligibles: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (Ql), Qualified Disabled and Working Individual (QDW1), QMB Plus, and SLMB Plus.

All costs of correctly paid medicaid services rendered after attainment of the age of fifty-five, if the person has not been determined to be permanently institutionalized, including any premium payments to managed care organizations.

TN# _ 09-021 Approval Date:! JUN -] 2050 Effective Date: _1/1/2010 Supersedes TN# _07-007

Introduction Page 53c

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE OF OHIO

CITATION LIENS AND ADJUSTMENTS OR RECOVERIES

1917(b)(2)(B) 42 CFR §433.36(h) — (i) (c) Adjustments or Recoveries: Limitations

The State complies with the requirements of section 1917(b)(2) of the Act and regulations at 42 CFR §433.36(h) — (i).

1917(b)(2)(A) (1) Adjustment or recovery of medical assistance correctly paid will be made only after the death of the individuals’ surviving spouse, and only when the individual has no surviving child who is either under age 21, blind, or disabled.

1917(b)(1)(B)(ii) (2) Medical assistance for Medicare cost sharing is protected from estate recovery for the following categories of dual eligibles [Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (Ql), Qualified Disabled and Working Individual (QDWI), QMB Plus, and SLMB Plus]. This protection extends to medical assistance for four Medicare cost sharing benefits (Part A and B premiums, deductibles, coinsurance and co-payments) with dates of service on or after January 1, 2010. The date of service for deductibles, coinsurance, and co-payments is the date the request for payment is received by the State Medicaid Agency. The date of service for premiums is the date the State Medicaid agency paid the premium.

1917(b)(3) (3) No money payments under another program are reduced as a means of adjusting or recovering Medicaid claims incorrectly paid.

TN# _ 09-021 Approval Date: JUN ~ 1.7010 Effective Date: _ 1/1/2010 Supersedes TN# _07-007

ATTACHMENT 2.2-A Page 9b

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE OF OHIO

CITATION CONDITION OR REQUIREMENT

A. Mandatory Coverage — Categorically Needy and Other Required Special Groups (Continued)

4902(a)(10)(E)(i) and 25. Qualified Medicare Beneficiaries -

1905(p) of the Act

1902(a)(10)(E)(ii), 1905(s), and 1905(p)(3)(A)(i) of the Act

a.

Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act);

Whose income does not exceed the income level (established at an amount up to 100 percent of the Federal income poverty level) specified in Supplement 1 to ATTACHMENT 2.6-A for a family of the same size; and

Whose resources do not exceed the standard calculated under subparagraph (D) of section 1860D-14(a)(3) of the Act.

(Medical assistance for this group is limited to cost sharing as defined in 3.2 of the introduction of this plan.)

26. Qualified disabled and working individuals —

a.

Who are entitled to hospital insurance benefits under Medicare Part A under section 1818A of the Act;

Whose income does not exceed the income level (established at an amount up to 200 percent of the Federal income poverty level); and

Whose resources do not exceed twice the maximum standard under SSI; and

Who are not otherwise eligible for medical assistance under Title XIX of the Act.

(Medical assistance for this group is limited to Medicare Part A premiums under sections 1818 and 1818A of the Act.)

TN# _ 09-021 Supersedes TN# _91-30

Approval Date: JUN - 1 2010 Effective Date: _ 1/1/2010

ATTACHMENT 2.2-A Page 9b1

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE OF OHIO

CITATION CONDITION OR REQUIREMENT

A. Mandatory Coverage — Categorically Needy and Other Required Special Groups

(Continued)

1902(a)(10)(E)(iii) and 27. 1905(p)(3)(a)(ii) of the Act

Specified Low-Income Medicare Beneficiaries —

Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act);

Whose income exceeds the income level in 25. b., but is less than 120 percent of the Federal poverty level.

Whose resources do not exceed the standard calculated under subparagraph (D) of section 1860D-14(a)(3) of the Act.

(Medical assistance for this group is limited to Medicare Part B premiums under section 1839 of the Act.)

4902(a)(10)(E)(iv) 27.1.

a.

Qualifying Individual —

Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under section 1818A of the Act;

Whose income is at least 120 percent of the Federal Poverty Level but less than 135 percent of the Federal Poverty Level; and

Whose resources do not exceed the standard calculated under subparagraph (d) of section 1860D-14(a)(3) of the Act.

(Medical assistance for this group is limited to Medicare Part B premiums under section 1839 of the Act.)

TN# _09-021 Supersedes TN# _93-04

Approval Date: JUN — 1.9010 Effective Date: _ 1/1/2010

ATTACHMENT 2.6-A Page 22

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

STATE OF OHIO

CITATION

CONDITION OR REQUIREMENT

1902(a)(10)(C)(i) of the Act

1860D-14, 1905(p)(1) and 1905(p)(2) of the Act.

1905(s) of the Act

7. Resource Standard — Medically Needy

a. Resource standards are based on family size.

b. Asingle standard is employed in determining resource eligibility for all groups.

c. In 1902(f) States, the resource standards are more restrictive than in 7.b. above for —

___. Aged ___. Blind ___ Disabled

Supplement 2 to ATTACHMENT 2.6-A specifies the resource standards for all covered medically needy groups. If the agency chooses more restrictive levels under 7.c., Supplement 2 so indicates.

Resource Standard — Qualified Medicare Beneficiaries, Specified Low-Income Beneficiaries and Qualifying Individuals

For Qualified Medicare Beneficiaries, Specified Low-Income Beneficiaries and Qualifying Individuals covered under section 1902(a)(10XE)i), 1902(a)(10)(E)iii) and 1902(a)(10)(iv) of the Act, the resource standard does not exceed the standard calculated under subparagraph (d) of section 1860D-14(a)(3) of the Act. This standard will be three times the SSI standard, adjusted annually by the increase in the Consumer Price Index (CPI) since 2006. For subsequent years, the resource standard will be increased by the annual percentage increase in the CPI rounded to the nearest multiple of $10.

For qualified disabled and working individuals covered under

"section 1902(aX10)(E)(ii) of the Act, the resource standard for

an individual or a couple (in the case of an individual with a spouse) is twice the SS! resource standard.

TN# _ 09-021 Supersedes TN# _91-27_

Effective Date: _ 1/1/2010

Approval Date: JUN — 1 2010

ATTACHMENT 2.6-A Page 22a

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF OHIO

CITATION CONDITION OR REQUIREMENT

9.1 For COBRA continuation beneficiaries, the resource standard is:

1902(u) of the Act Twice the SSI resource standard for an individual.

More restrictive standard as applied under section 1902(f) of the Act as described in Supplement 8 to Attachment 2.6-A.

TN# _09-021 Approval Date! JJN — J 2010 Effective Date: _ 1/1/2010 Supersedes

TN# _93-004

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL I. TRANSMITI AL NUMBER: 0 9 - 0 2 I revised 2. STATE OHIO FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE January I, 2010 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN cgi AMENDMENT COMPLETE BLOCKS 6 THRU l 0 IF THIS IS AN AMENDMENT Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: MIPPA § 112: 1902(a)(lO)(E), 1860D-l4(a)(3), l905(p), 1905(s) a. FFY 2010 $101 Please see Attachment A for explanation. MIPPA § 115: l092(a) lO) E), 1917 b)(l B b. FFY 201 l $135 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Page 53a-2 Page 53c Att. 2.2-A, Page 9b Att. 2.2-A, Page 9bl Att. 2.6-A, Page 22 Att. 2.6-A, Page 22a 10. SUBJECT OF AMENDMENT: OR ATTACHMENT (If Applicable): Page 53a-2 (TN 07-007) Page 53c (TN 07-007) Att. 2.2-A, Page 9b (TN 91-30) Att. 2.2-A, Page 9bl (TN 93-04) Att. 2.6-A, Page 22 (TN 91-27) Att. 2.6-A, Page 22a (TN 91-27) The proposed amendment updates five State Plan Amendment pages to reflect the new resource limit for Medicare Savings Plans, as amended by MIPP A section 112. The proposed amendment addresses MIPPA section 115 by exempting Medicare cost sharing from Medicaid estate recovery for six categories of dual eligibles with dates of service on or after January l, 2010. 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFI,s:;_IAL: l:8J OTHER, AS SPECIFIED: Governor bas delegated signature authority to ODJFS Director. Director bas delegated signature authority to State Medicaid Director 16. RETURN TO: ~u-u,; J rloluk / . .._, -13-.-TYP-E_D_N_AM_E_:_T_RA_C_Y_J+., P_L_O_U_C_K--"-'-~'--c_+-""'-='.__ _ __, Becky Jackson OHP/Bureau of Health Plan Policy -14-.-T-IT_L_E_: ____ S_T_A_T_E_M_E_D_I_C_AID __ D_IRE_C_T_O_R ___ ---1 ~~oB~~·:;;;~~t of Job and Family Services -15-. _D_A_T_E_S_UB_MI_TT_E_D-.-. ----l-l/4-/-20-0-9---------1 Columbus, Ohio 43218 FOR UGIONALOfflCE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: 19. EFFECTIVE DATE Of APPROVED MATERIAL: 010 - Instructions on Back FORM CMS-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

Center for Medicaid and State Operations (CMSO)

CENTERS for MEDICARE & MEDICAID SERVICES

Ms. Tracy Plouck, Deputy Director

Office of Ohio Health Plans

Ohio Department of Job and Family Services P.O. Box 182709

50 West Town Street, Suite 400

Columbus, Ohio 43218

RE: Ohio 09-027

Dear Ms. Plouck:

MAR 1 5 2010

We have reviewed the proposed amendment to Attachment 4.19-A of your Medicaid State plan submitted under transmittal number (TN) 09-027. Effective for services on or after November 30, 2009, this amendment revises dates and filing requirements for the hospital cost report for reporting periods ending

in State fiscal year 2009.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), 1903(a), and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment 09-027 is approved effective November 30, 2009. We are enclosing the HCFA-179 and the

amended plan pages.

If you have any questions, please call Todd McMillion at (608) 441-5344.

Sincerely,

y Cindy

Director

Balidel:

Center for Medicaid and State Operations

Attachment 4.19 - A

$101:3-2-23 Cost reports.

(A) For cost-reporting purposes, the medicaid program requires each eligible provider, as defined in rule 5101:3-2-01 of the Administrative Code, to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations. Cost reports must be filed within one hundred eighty days of the end of the hospital's cost-reporting year. Extensions of this one hundred eighty day period shall be granted if the centers for medicare and medicaid services (CMS) of the United States department of health and human services extends the date by which the hospital must submit its cost report for the hospital's cost-reporting period. Failure to submit all necessary items and schedules will only delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (H) of this rule.

Effective for medicaid cost reports filed for cost-reporting periods ending in state fiscal year (SFY) 2003, and each cost-reporting period thereafter, any hospital that fails to submit cost reports on or before the dates specified by ODJFS shall be fined one thousand dollars for each day after the due date that the information is not reported.

The hospital shall complete and submit the JFS 02930 "Hospital Cost Report" in accordance with instructions contained in this rule. The JFS 02930 (rev. 3/20084/2009) for SFY 2008 2009 and its instructions are shown in the appendix to this rule. The hospital's cost report must:

(1) Be prepared in accordance with medicare principles governing reasonable cost reimbursement set forth in the providers' reimbursement manual "CMS

Publications 15, 15-1 and 15-2," available at http://www.cms.hhs.gov/Manuals/PBM/list.asp#TopOfPage dated September 8, 2005.

(2) Include all information necessary for the proper determination of costs payable under medicaid, including financial records and statistical data.

(3) Be submitted in accordance with the instructions in the appendix to this rule an electronic copy of the medicare cost report, which must be identical in all respects to the cost report submitted to the medicare fiscal intermediary.

(4) Include the cost report certification executed by an officer of the hospital attesting to the accuracy of the cost report and to the accuracy of the OBRA survey. In addition, all subsequent revisions to the cost report must include an executed certification.

(5) Effective for medicaid cost reports filed for cost-reporting periods ending in SFY 2003, and each cost-reporting period thereafter, the executed

“TN No, 09-027 Approval Bate MAR 1 5 2010 SUPERSEDES TN No. 08-009 Effective Date: 11-30-2009

Attachment 4.19 - A

5101:3-2-23 2

certification shall require the officer of the hospital to acknowledge that an independent party, a certified public accountant, has successfully verified the data reported on "Schedule F" of the cost report in accordance with the procedures included in the cost report instructions. In addition, all subsequent revisions to "Schedule F" shall also be successfully verified by an independent, certified public accountant in accordance with the recertification procedures included in the cost report instructions.

(B) Hospitals having a distinct part psychiatric or rehabilitation unit recognized by medicare in accordance with the provisions of 42 C.F.R. 412.25 effective October 1, 2006, 42 C.F.R. 412.27 effective July 1, 2006, and 42 C.F.R. 412.29 effective January 1, 2005, must identify distinct part unit costs separately within the cost report as described in paragraph (A) of this rule.

(C) Ohio hospitals performing transplant services covered under medicaid as described in tule 5101:3-2-07.1 of the Administrative Code must identify transplant costs, charges, days, and discharges separately within the cost report as described in paragraph (A) of this rule.

(D) Ohio hospitals performing ambulatory surgery within the hospital outpatient setting must identify ambulatory surgery costs and charges separately within the cost report as described in paragraph (A) of this rule.

(E) Ohio hospitals providing services to medicaid managed care plan (MCP) enrollees must identify MCP costs, charges and payments separately within the cost report as described in paragraph (A) of this rule.

(F) It is not necessary for the hospital to wait for the medicare (Title XVIII) audit in order to file the initial cost report for the stated time period. The interim cost report filing can be audited by the ODJFS prior to any applicable final adjustment and settlement. If an amount is due ODJFS as a result of the filing, payment must be forwarded, in accordance with the instructions in the appendix to this rule, at the time the cost report is submitted for it to be considered a complete filing. Any revised interim cost report must be received within thirty days of the provider's receipt of the interim cost settlement. A desk audit will be performed by the hospital audit section on all as filed and interim cost reports. An interim cost settlement by ODJFS does not preclude the finding of additional cost exceptions in a final settlement for the same cost-reporting period.

(1) If an amended medicare cost report is filed with the medicare fiscal intermediary, a copy of the amended medicare cost report must be filed with the hospital audit section. Information contained in the amended medicare cost report will be incorporated into the interim cost report, as originally filed,

MAR 1 5 2010

TN No. 09-027 Approval Date: SUPERSEDES TN No. 08-009 Effective Date: 11-30-2009

Attachment 4.19 - A

5101:3-2-23 3

if received prior to interim settlement; otherwise, it is subject to the provisions of paragraph (F) of this rule.

(2) Adjustments may be made to the interim cost report as described in rule 5101:3-2-24 of the Administrative Code.

(G) Out-of-state providers that are not paid on a prospective payment basis and provide inpatient and/or outpatient services to eligible Ohio Title XIX recipients will be required to file the cost report identified in this rule.

(H) Hospitals that fail to submit cost reports timely as defined in paragraph (A) of this rule will receive a delinquency letter from the ODJFS and are subject to notification that thirty days following the date on which the cost report was due, payments for hospital services will be suspended. Suspension of payments will be terminated on the fifth working day following receipt of the delinquent cost report. Claims affected by suspension of payment are not considered to be clean claims as "clean claims" are defined in rule 5101:3-1-19.3 of the Administrative Code. At the beginning of the third month following the month in which the hospital cost report became overdue, if the cost report has not yet been submitted, termination of the provider from the program will be recommended in accordance with Chapter 5101:3-1 of the Administrative Code.

MAR 1 5 2010

TN No. 09-027 Approval Date: SUPERSEDES TN No. 08-009 Effective Date: 11-30-2009

5101:3-2-23

Effective:

R.C. 119.032 review dates:

Attachment 4.19 - A

09/01/2012

Certification

Date

Promulgated Under: Statutory Authority: Rule Amplifies: Prior Effective Dates:

119.03

5111.02

5111.02, 5111.021

4/7/77, 12/30/77, 3/21/81, 11/11/82, 1/1/84, 10/1/84, 7/29/85, 10/1/85 (Emer), 12/22/85, 10/19/87, 4/23/88, 8/1/88 (Emer), 10/21/88, 2/22/89 (Emer), 5/8/89, 11/5/89, 5/25/90, 5/1/91, 5/1/92, 10/1/93 (Emer), 11/15/93, 1/20/95, 3/16/96, 7/1/96, 7/1/97, 4/26/99, 7115/99, 10/18/99, 5/1/00, 5/17/01, 3/27/03, 7/17/03, 9/2/04, 9/17/05, 11/9/06, 9/17/07, 7/17/08

MAR 1 5 2010

TN No. 09-027 Approval Date: SUPERSEDES TN No. 08-009 Effective Date: 11-30-2009

Attachment 4.19 - A

Page 1 of 51

Ohio Department of Job and Family Services

HOSPITAL COST REPORT (JFS 02930)

INSTRUCTIONS

For State Fiscal Year 2009

TN No. 09-027 Approval pdfAR 1 5 2010 SUPERSEDES TN No. 08-009 Effective Date: 11-30-2009

JFS 02930-I (Rev. 4/2009)

Attachment 4.19 - A

Page 2 of 51

Table of Contents

GENERAL INSTRUCTIONG.......ccccsccsssessssseeseessesensenesseeeseessrssssesaessenseesensssuassescousaesaaesseesssesresnesaeeaes 3 FILING DEADLINE....... REQUIRED FILINGS . FILING EXTENSIONS. ......sesssssersesessneeecseeseees AMENDED FILINGS. ..........cccseseesesseesteeseeseeeenees IMPORTANT REMINDERS... CHANGES .....esseeseeseeeseeee

SCHEDULE A.......cscccssssesssesnseeeesseeeneeneneenessaees i

SCHEDULE B......cescssccscceceesseeseeereeseeeeacseeseeeeesnssereasessesesscaeessessnssatssapessusaeeceeeneeeseseanensesseananeoeeanas 6

SCHEDULE C.......cccccssescesseessceseesseeeccsesssavsesseeeseeesesssesenesseesaessesrsssseassunsassgsvsnsneceseesssesseensarseeageniee 8

SCHEDULE C-1..

SCHEDULE C-2..

SCHEDULE D ....

SCHEDULE D-1 .

SCHEDULE E..... nl4 SCHEDULE Foon sssvsccceccsssmneseesesssvvsesseevvnnnssesesssssineseeesnesnsnee met INDEPENDENT THIRD PARTY VALIDATION OF SCHEDULE F DATA....ssssssssssssssccessssssescssessssees 15

GENERAL INSTRUCTIONS (APPLIES TO ALL OF SECTION 1).....scssssssssersesesesessnssenssesensnseeseseess 17 SECTION I (UNCOMPENSATED CARE FOR ACUTE CARE HOSPITALS) we 18 Instructions for COIUMN 1.......esccseessesseeccseeessesntessseeeeessseeeeees we 18 Instructions for Column 2........ Instructions for Column 3........ Instructions for Columns 4 and 5. wl Instructions for COIUMN 6........ccsseeeeceees wu 2l Instructions for COLUMN 7.......cccceseeeeeeseeesseeeeessneeesseneeeerenseaneeeseneee vee 23 SECTION II (FREE-STANDING PSYCHIATRIC HOSPITAL INFORMATION) . .25 SCHEDULE G .27 SCHEDULE H ... .28 SCHEDULE 1.......... 31 Cost Report SChEdUles........scscsssscssssesssseesessesesrssesssssssterssesseesenessseecassusesaeerseessesesscensnssenieneagsg® 33 MAR 1 5 2010 TN No. 09-027 Approval Date: JFS 02930-I (Rev. 4/2009) SUPERSEDES

TN No. 08-009 Effective Date: 11-30-2009

Attachment 4.19 - A

Page 3 of 51

GENERAL INSTRUCTIONS

Please read and follow all instructions carefully. Jnstructions that pertain to DRG-exempt and out-of-state hospitals will be in italics throughout the cost report instructions. If you have questions about the instructions or report please contact Jeff Runkle of the Hospital Unit, (614) 752-4427.

The cost report schedules should be completed in order, from A to I. Within the report, the line numbers for the revenue centers are set up to closely match the CMS-2552-96 in order to allow for easy transfer of data.

UB-92 revenue center codes should be grouped as shown on the attached sheets for inpatient and outpatient services. If this is not possible YOU MUST specifically identify any differences in groupings on the enclosed BILLING CODE ALLOCATION sheet(s) and return them with the completed cost report. When differences in groupings exist but are not identified by the report filer, ODJFS groupings will be used at the time of settlement.

Report only data and discharges occurring within the fiscal period covered by this cost report. FILING DEADLINE

Rule 5101:3-2-09, of the Ohio Administrative Code states in part “...any hospital that fails to report the information required under this rule on or before the dates specified in this rule and in rule 5101:3-2-23 of the administrative code shall be fined one thousand dollars ($1,000.00) for each day after the due date that the information is not reported.”

The completed cost report MUST BE POSTMARKED on or before June 30, 2009 for those hospitals filing with a cost reporting period ending between July 1, 2008 and December 31, 2008. For

those hospitals filing with a cost report period ending between January 1, 2009 and June 30, 2009, the report is to be postmarked no later than December 31, 2009.

REQUIRED FILINGS

Your completed cost report filing MUST include:

- the completed CMS-2552-96 electronic cost report (EC) and print image (PI) files - all completed applicable JFS 02930 schedules

- Email the CMS-2552-96 (EC & PI files) and JFS 02930.xIs to: hospital_cost_reports@jfs.ohio.gov If unable to email, please contact ODJFS.

- Mail the following cost report information to:

Via Regular Mail (preferred) Via Parcel Carriers (not required) Ohio Health Plans Ohio Health Plans

Cost Reporting Unit Cost Reporting Unit

P.O. Box 182709 50 W. Town Street, Ste 400, 4" Floor Columbus, OH 43218-2709 Columbus, OH 43215-4142

An original SIGNED JFS 02930 Certification Page A hard copy of the JFS 02930 schedules and OBRA Survey A copy of the SIGNED CMS-2552-96 Certification Page

- Remittance for amounts due with copy of settiement page should be mailed to: Ohio Department of Job and Family Services P.O. Box 182367 Columbus OH 43218-2367 MAR 1 5 2010

TN No. 09-027 Approval Date:

JFS 02930-I (Rev. 4/2009) SUPERSEDES TN No. 08-009 Effective Date: 11-30-2009

Attachment 4.19 - A

Page 4 of 51

- Make checks payable to: Treasurer of State, State of Ohio (ODJFS)

In filings are j t fine descrii bove. FILING EXTENSIONS

Requests for an extension of the filing deadline, for no more than one 30 day period, must be made in advance, in writing, to Ohio Health Plans, Cost Reporting Unit, P.O. Box 182709, Columbus, OH 43218- 2709.

If Medicare grants an extension that would go beyond the above one-time 30 day extension, documentation must be provided. Please submit your request in writing to the above address and include a copy of the Medicare extension letter. The filing deadline will be 30 days after the required filing date of the Medicare Cost Report. No further extensions will be granted.

AMENDED FILINGS

Amended CMS-2552-96 reports filed by hospitals with the Medicare intermediary must also be filed with ODJFS. No amendments to the JFS 02930 will be accepted later than 30 days after the hospital's receipt of the audited interim settlement.

IMPORTANT REMINDERS

The Upper Limit Payments (UPL) payments reported on Schedule H, col. 1, line 5 should be recorded gross, not net.

The OBRA Survey must be completed in its entirety.

Out-of-State providers that are paid on a prospective payment basis are NOT required to file a cost report.

CHANGES

e The cost report instructions and forms have been updated to reflect dates and filing deadlines relevant to the SFY 2009 Reporting Periods.

e Schedule C-1 — Discharge Statistics. This schedule has been expanded to allow hospitals to report Medicaid Managed Care Plan discharges based on the date the hospital's Fee-for- Service Capital Rate changes.

e Schedule C-2 — Medicaid HMO Days. All hospitals serving persons enrolled in a Medicaid Managed Care Plan (HMO) are required to complete this schedule. The purpose of this change is to accurately calculate the cost of providing these services for use in the Hospital Care Assurance Program model.

e Schedule E — Line 7b has been added to facilitate the reporting of payments received under Section 1011. This information will be included in the calculation of the hospital specific OBRA cap.

e Schedule E — The formula for calculating the cost-to-charge ratios used to determine Uncompensated Care Costs have been changed to use both the Fee-for-Service and HMO cost and charge data from Schedules D and I.

TN No. 09-027 Approval paWlAR 15 2010

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SCHEDULE A

MISCELLANEOUS REVENUES

Note - Throughout the JFS 02930 cost report instructions "Worksheet" refers to Medicare's CMS- 2552-96 and "Schedule" refers to the JFS 02930.

Lines 1 - 24 - Enter all amounts included on Worksheet G-2 which are not included on the Worksheet C, column 8. Examples may include, but are not limited to: Home Health, Hospice, Organ Acquisition, Professional Fees (detailed by cost center), etc.

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SCHEDULE B

COST DISTRIBUTION

Column 1 Lines 25-34, 37-97, and 100 - Enter total cost figures from Worksheet C, Part I, column 5 for each revenue center. Note: Report costs for Organ Acquisition, Hospice, and Home Health Agency from

Worksheet B, part I, column 27. For free-standing psychiatric hospitals, do not report costs associ with residential treatment.

Line 100 - Enter Observation Bed costs only if these costs are included both on line 25 and on line 62.

Column 2

Lines 25-34 and 37-97 - Enter all Interns and Residents costs that were removed from total cost reported on Worksheet B part I, column 26. Include drug costs related to Renal Dialysis or Home Program Dialysis that were also removed from total costs.

Column 3 Lines 25 - 97 - Enter the total of columns 1 and 2.

Column 4 For any revenue center that has costs but no corresponding charges, enter a charge of one dollar ($1.00).

Lines 25-97 - Record total charges from Worksheet C, part I, column 8. Line 100 - Enter one dollar ($1.00) if an amount is entered in column 3, line 100.

Column 5 Lines 25-34, 37-97, and 100 - Divide each line amount in column 3 by the corresponding line amount in column 4 and enter the result rounded to six decimal places.

Column 6

Lines 25-34 and 37-97 - Enter the total allowable inpatient charges from Worksheet C, part I, column 6 for each revenue center. (Note: Subprovider services reimbursed on a cost basis by Medicare but reimbursed by Medicaid on the DRG system must be included in this column; i.e., Distinct Part Psychiatric services. Do not enter data for those revenue centers not eligible for cost reimbursement or DRG payment, e.g. Home Health Agency, SNF, Hospice, Ambulance, residential treatment).

Line 100 - If Observation in line 62 and included in line 25, enter one dollar ($1.00).

Column 7 Lines 25-34, 37-97, and 100 - Multiply the charges in column 6 by the corresponding ratio in column 5. Enter the result rounded to the nearest dollar.

Column 8

Lines 25-34 and 37-97 - Enter the total allowable outpatient charges from Worksheet C, part I, column 7 for each revenue center. Do not include amounts for those revenue centers previously not eligible for cost reimbursement, i.e., Outpatient Laboratory, S.N.F. Ancillary, Hospice, Home Health Agency, and Ambulance.

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Column 9 Lines 25-34 and 37-97 - Multiply the charges in column 8 by the corresponding ratio in column 5 and enter the result rounded to the nearest dollar.

Column 10 Lines 25-34 and 37-97 - Enter charges for revenue centers that are not eligible for cost reimbursement, i.e., Outpatient Laboratory, S.N.F. Ancillary, Hospice, Home Health Agency, and Ambulance.

Column 11

Lines 25-34 and 37-97 - Multiply the charges in column 10 by the corresponding ratio in column 5 and enter the result rounded to the nearest dollar.

Columns 1-11 Line 35 - Enter the total of lines 25 through 34.

Line 98 - Enter the total of lines 37 through 97. Line 99 - Enter the total of lines 35 and 98. Line 101 - Enter the total of line 99 less line 100.

i 1. 4 mi ] m_of cols. 10. s ind c -foot all columns.

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SCHEDULE C

CALCULATION OF ROUTINE COSTS

Column 1 - Transfer amounts from Schedule B, column 7, lines 25-33 to the appropriate lines. Enter the sum of lines 25-33 on line 35.

Column 2 - Swing Beds - Transfer to line 25 the amount on Worksheet D-1, part I, line 26 as negative amounts. Enter the sum of lines 25-33 on line 35.

Column 3 - For each line enter the sum of columns 1 and 2. Enter the sum of lines 25-33 on line 35.

Column 4 - Enter the total days from Worksheet S-3, part I, column 6 to the appropriate lines. If there are Observa jon jays re, rted on Worksh t S-3 line 26 column 6, or Em lo ee Discount D

For Observation Bed days assigned directly to a subprovider, those days should be included with the subprovider’s days rather than | in Adults & Pediatric, line 25. Do not include swing bed days. For free-standin h Is, do not in sidential tmen Enter the sum of

lines 25-33 on line 35.

Column 5 - Divide each line amount in column 3 by the corresponding days in column 4 for lines 25-33 and enter the result rounded to two decimal places.

Column 6 - For each revenue center, enter the number of covered days of service rendered to Title XIX

patients Gscharged during the reporting period. Bonet include Observation Bad days or non-covered bed,

Cee setvices that Enter the sum of lines 25-33 on line 35.

Column 7 - For each revenue center, multiply the per diem calculated in column 5 by the XIX days reported in column 6 and enter the result rounded to the nearest dollar. Enter the sum of lines 25-33 on line 35.

Column §& - For each revenue center, enter the number of covered days of service rendered to Title V

patients discharged during the reporting period. Do not include Observation Bed days or non-covered days. Enter the sum of lines 25-33 on line 35.

Column 9 - For each revenue center, multiply the per diem calculated in column 5 by the Title V days reported in column 8 and enter the result rounded to the nearest dollar. Enter the sum of lines 25-33 on line 35.

Column 10 - For each revenue center, enter the number of covered days of service rendered to Title XIX transplant patients discharged ag the reporti ing period ude onl nsplan i id on

services paid by DRG. Enter the sum of lines 25-33 on line 35.

Column 11 - For each revenue center, multiply the per diem calculated in column 5 by the Title XIX transplant days reported in column 10 and enter the result rounded to the nearest dollar. Enter the sum of lines 25-33 on line 35.

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SCHEDULE C-1

DISCHARGE STATISTICS As defined in Ohio Administrative Code, rule 5101:3-2-02 (B)(17): A patient is said to be "discharged" when he or she:

(a) Is formally released from a hospital

(b) Dies while hospitalized

(c) Is discharged, within the same hospital, from an acute care bed and admitted to a bed in a psychiatric unit distinct part as described in paragraph(B)(8) of this rule or is discharged within the same hospital, from a bed in a psychiatric unit distinct part to an acute care bed;

(d) Signs self out against medical advice (AMA).

The discharges reported on this schedule should also include the number of patients transferred to other facilities.

SECTION I

Column 1 - Enter, from Worksheet S-3, part I, column 15, the number of discharges for each revenue center. Enter the sum of lines 36-39 on line 40.

Columns 2-4 - Enter the number of discharges from the facility for program patients. Title XIX services are classified by various rate years. Your fiscal year may not include every category. Only report discharges into the category that corresponds with your fiscal year. Enter the sum of each column on line 40. Include in

columns 2 and 3 any discharges for transplant services that are paid on a DRG basis. Any

Column 2-4, line 41 - Enter your capital add-on rate for the periods for which you reported discharges. Columns 7 & 8 - Enter the number of discharges from the facility for Medicaid HMO enrolled patients. Medicaid HMO services are classified by various rate years. Your fiscal year may not include every category. Only report discharges into the category that corresponds with your fiscal year. Enter the sum of each column on line 40.

SECTION II

Outpatient visits should be counted as the number of final outpatient claims for which a hospital was paid and/or expects to receive payment. Series accounts/cycle bills should be counted as 1 visit per claim (not the number of dates of service on that claim). Observation and emergency services claims should be counted as outpatient visits unless these visits turned into inpatient admissions on the same date of service.

Line 42, column 1 - Enter the number of total facility outpatient visits.

Line 42, column 2 — Enter the number of Medicaid outpatient visits on or before 12/31/07.

Line 42, column 3 - Enter the number of Medicaid outpatient visits on or after 1/1/08.

SECTION III

Line 43 - Enter as a sum, the number of beds on Worksheet S-3, part I, column 1, lines 12 and 14.

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Line 44 - Enter as a sum, the net number of interns and residents in an approved teaching program on Worksheet S-3, part I, column 9, lines 12, and 14.

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SCHEDULE C-2

MEDICAID HMO INPATIENT DAYS

Column 1 — Enter the per diem amounts from Schedule C, column 5, for each cost center in Lines 25 — 33.

Column 2 - For each revenue center, enter the number of covered days of service rendered to Medicaid HMO patients discharged during the reporting period. Enter the sum of lines 25-33 on line 35.

Column 3 —~ For each revenue center, multiply the per diem calculated in column 5 by the Medicaid HMO days reported in column 3 and enter the result rounded to the nearest dollar. Enter the sum of lines 25-33 on line

35.

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TITLE XIX COST CALCULATIONS

Column 1 - Enter the ratio from Schedule B, column 5, for each revenue center on the corresponding line.

Column 2

Lines 25-33 and 37-97 - Enter the charges for covered Title XIX inpatient services rendered during the

reporting period. ude transplant servi hat are reimbu

Column 3

RG basis.

Lines 25-33 - Transfer the cost amounts from Schedule C, column 7, lines 25 to 33.

Lines 37-97 - Multiply the charges in column 2 by the corresponding ratio in column 1. Enter the result

rounded to the nearest dollar.

Column 4 Lines 25-33 - r cha for cov ient servi nly i tient ch re reported on Schedule B.

Lines 37-97 - Enter the charges for covered outpatient services. Do not include charges for Outpatient Laboratory Services, or any services which are not cost settled, (e.g., Pregnancy services).

Column 5

Lines 25-33 and 37-97 - Multiply the charges in column 4 by the corresponding ratio in column 1. Enter

the result rounded to the nearest dollar.

Column 6

Lines 41-44 and 70-97 - Enter the charges for Outpatient Laboratory Services.

Column 7

Lines 41-44 and 70-97 - Multiply the charges in column 6 by the corresponding ratio in column 1. Enter

the result rounded to the nearest dollar.

Column 8

Lines 25-33 and 37-97 - Report only allowable charges for transplant services that are reimbursed on a

reasonable cost basis during the reporting period. Column 9

Lines 25-33 - Transfer the cost amounts from Schedule C, column 11, lines 25-33.

Lines 37-97 - Multiply the charges in column 8 by the corresponding ratio in column 1. Enter the result

rounded to the nearest dollar.

‘olumns 2- “9 Line 35 - Enter the total of lines 25 through 33.

Line 98 - Enter the total of lines 37 through 97.

Line 101 - Enter the total of lines 35 and 98.

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SCHEDULE D-1

TITLE V COST CALCULATIONS

Column 1 Lines 25-33 and 37-97 - Transfer total cost amounts from Schedule B, column 3, to the corresponding lines.

Column 2 Lines 25-33 and 37-97 - Enter the amount of cost associated with combined billing of provider based physician professional services as reported on Worksheet A-8-2, column 4.

Column 3 Lines 25-33 and 37-97 - Enter the sum of columns 1 and 2.

Column 4 Lines 25-33 and 37-97 - Transfer the total charge amounts from Schedule B, column 4, to the corresponding lines.

Column 5 Lines 25-33 and 37-97 - Enter the amount of charges associated with the costs of combined billing of provider based physician professional services that are reported in column 2.

Column 6 Lines 25-33 and 37-97 - Enter the sum of columns 4 and 5.

Column 7 Lines 25-33 and 37-97 - Divide column 3 by column 6 and enter the resulting ratio, rounded to six decimal places, for each cost center.

Column 8 Lines 25-33 and 37-97 - Enter the charges for covered inpatient Title V services rendered during the cost reporting period.

Column 9

Lines 25-33 - Transfer the cost amounts from Schedule C, column 9.

Lines 37-97 - Multiply the charges in column 8 by the corresponding ratio in column 7. Enter the result rounded to the nearest dollar.

Column 10 Lines 25-33 and 37-97 - Enter the charges (including Outpatient Laboratory and Radiology services for covered outpatient Title V services) rendered during the reporting period.

Column 11 Lines 25-33 and 37-97 - Multiply the charges in column 10 by the corresponding ratio in column 7. Enter the result rounded to the nearest dollar.

Columns 1-11 Line 35 - Enter the total of lines 25 through 33.

Line 98 - Enter the total of lines 37 through 97.

Line 101 - Enter the total of lines 35 and 98. MAR 1 5 2010 , TN No. 09-027 Approval Date:

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SCHEDULE E

MEDICAL EDUCATION COSTS AND MISCELLEANOUS DATA

MEDICAL EDUCATION COSTS

Line 1 — Enter the amount from Worksheet B, part I, column 20 — 20.XX, line 95.

Line 2 — Enter the amount from Worksheet B, part I, column 21 — 21.XX, line 95.

Line 3 — Enter the amount from Worksheet B, part I, columns 22 — 22.XX and 23 - 23.XX, line 95. Line 4 — Enter the amount from Worksheet B, part I, column 24 — 24.XX, line 95.

Line 5 — Enter the total of lines 1 through 4.

XIX OUTPATIENT LAB PAYMENTS Line 6 - Enter the total Title XIX Outpatient Lab payments received that relate to charges reported on Schedule D, column 6, line 44.

NET PATIENT REVENUES | SECTION 1011 PAYMENTS

Line 7a — Enter the Net Patient Revenue amount from Worksheet G-3 line 3.

Line 7b — Enter the amount received for services provided under Section 1011 — Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens. For additional information regarding Section 1011, please visit the following websites; http://www.trailblazerhealth.com/Section_1011/Default.aspx? or

http://www.cms.hhs.gov/MLNProducts/downloads/Section 1011 Fact Sheet.pdf

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SCHEDULE F HOSPITAL CARE ASSURANCE UNCOMPENSATED CARE

OUT-OF-STATE HOSPITALS SHOULD NOT COMPLETE THIS SCHEDULE. OHIO ACUTE CARE HOSPITALS SHOULD COMPLETE SECTION I PSYCHIATRIC HOSPITALS SHOULD COMPLETE SECTION II

INDEPENDENT THIRD PARTY VALIDATION OF SCHEDULE F DATA

Effective for Medicaid Cost Reports filed for cost reporting periods ending in State Fiscal Year (SFY) 2003, and each cost reporting period thereafter, each hospital, shall be required to have an independent party, external to the hospital, verify the data reported on Schedule F. The external reviewer shall at a minimum perform the data verification based on a set procedure as follows.

1. Verify that patient logs are maintained for the following categories of patients: e — Disability Assistance inpatient charges, with insurance Uncompensated care inpatient charges < 100% federal poverty income limits (FPL), with insurance Disability Assistance outpatient charges, with insurance Uncompensated care outpatient charges < 100% FPL, with insurance Disability Assistance inpatient charges, with no insurance Uncompensated care < 100% FPL, inpatient charges, with no insurance Uncompensated care > 100% FPL, inpatient charges, with no insurance Disability Assistance outpatient charges, with no insurance Uncompensated care < 100% FPL, outpatient charges, with no insurance Uncompensated care > 100% FPL, outpatient charges, with no insurance

2. Verify that the Hospital's patient logs include a date-of-service. Verify that the service dates for accounts with Disability Assistance coverage or family income < 100% FPL are recorded in the cost report period in which they occurred, and that the write-off dates for accounts with family incomes >100% FPL, are recorded in the cost report period in which they were written-off. Verify that each log entry includes a unique (unduplicated) identifier for the patient, that is unique to the patient and not to each visit by the patient.

3. Verify that the supporting patient log totals for the data elements listed below agree to each data element on the Hospital's JFS 02930 Schedule F. If any of the elements do not match, return the patient logs to Hospital for correction. ¢ Line 8, Columns 1 and 6 — Disability Assistance inpatient charges and receipts, with insurance e Line 9, Columns 1 and 6 — Uncompensated care < 100% FPL inpatient charges and receipts , with insurance e Line 12, Columns 1 and 6 — Disability Assistance, outpatient charges and receipts, with insurance e Line 13, Columns 1 and 6 — Uncompensated care < 100% FPL, outpatient charges and receipts, with insurance ¢ Line 8, Columns 2 and 7 ~ Disability Assistance, inpatient charges and receipts, with no insurance ¢ Line 9, Columns 2 and 7 — Uncompensated care < 100% FPL, inpatient charges and receipts , with no insurance ¢ Line 10, Columns 2 and 7 —- Uncompensated care > 100% FPL, inpatient charges and receipts, with no insurance Line 12, Columns 2 and 7 — Disability Assistance outpatient charges and receipts, with no insurance Line 13, Columns 2 and 7 — Uncompensated care < 100% FPL, outpatient charges and receipts, with no insurance ¢ Line 14, Columns 2 and 7 —- Uncompensated care > 100% FPL, outpatient charges and receipts, with

no insurance MAR 1 5 2010 TN No. 09-027 Approval Date: JFS 02930-I (Rev. 4/2009) SUPERSEDES TN No. 08-009 Effective Date: 11-30-2009

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4. Verify the mathematical accuracy of Hospital's logs, by using at least the methodologies described below. If the logs were totaled manually, request adding machine tapes and match a sample of 10 entries on two of the tapes to the corresponding entries on the patient logs. If the logs were totaled with the use of an electronic spreadsheet, verify the accuracy of the formula(s) used. If the log entries were taken directly from the hospital's mainframe computer system, select one of the categories in Step 3 and tally the entries. If the logs do not foot, return the logs, and, if appropriate, the tapes to Hospital for correction.

5. From the hospital logs, select a random sample of entries from each of the ten data elements listed in Step 3, and verify the appropriateness of the write-off. The appropriateness of the write-off for each account selected shall be determined in accordance with Ohio Administrative Code (OAC) 5101:3-2-07.17 and the hospital's policies regarding the documentation of applicants’ incomes.

The size of the required sample will vary according to which of three tiers the Hospital is placed in, using data from the current cost reporting period:

e — If the hospital reports total uncompensated care charges for patients without insurance that is less than $5.0 million, the size of the sample shall be at a minimum, 32 accounts: four in each of the six data categories identified in Step 3 for patients with no insurance and two in each of the categories for patients with insurance.

¢ — If the hospital reports total uncompensated care charges for patients without insurance that is greater than $5.0 million but less than $10.0 million, the size of the sample shall be at a minimum, 64 accounts: eight in each of the six data categories identified in Step 3 for patients with no insurance and four in each of the categories for patients with insurance.

¢ If the hospital reports total uncompensated care charges for patients without insurance that is greater than $10.0 million, the size of the sample shall be at a minimum, 96 accounts: 12 in each of the six data categories identified in Step 3 for patients with no insurance and six in each of the categories for patients with insurance.

¢ In addition to the above sample criteria, review all accounts for patients in the uncompensated care < 100% FPL, with no insurance categories which show receipts.

6. Obtain itemized statements from the Hospital for each of the patient accounts identified in the random selection of data elements identified in Step 5. Match the itemized statement to its corresponding entry in Hospital's log. Verify that patient accounts were correctly logged and entered in Schedule F, based on insurance status.

From the itemized statement, verify the patient's name, the date(s) of service, and whether the account is inpatient or outpatient and corresponds with the log entry. Subtract from the itemized statement any charges for services that can not be counted as "basic, hospital level" as described in OAC 5101:3-2-07.17 and OAC 5101:3-2-02, Appendix A. Verify that the sum of any subtraction of non-hospital level charges matches or does not exceed the entry for gross charges in Hospital's log. Verify that the total of all receipts on each selected account matches the receipts shown in the Hospital's log.

7. Obtain a copy of the Hospital's internal policy outlining its procedures for documenting applications for HCAP qualifying charity care or write-off.

8. Obtain copies of the documentation the Hospital used to determine eligibility for each of the patient accounts identified in the random selection of data elements identified in Step 5. Verify that the hospital's documentation practices are supported by its policy statement, obtained in Step 7, and are in accordance with OAC 5101:3-2-07.17.

9. From the eligibility documentation outlined in Step 8, verify that the patients were residents of Ohio, and Not eligible for Medicaid according to OAC 5101:3-2-07.17. Verify that the patient accounts logged as eligible for Disability Assistance (DA) were in fact eligible for DA on the date(s) of service. For accounts of patients <100 % FPL, verify that Hospital used the appropriate Federal Poverty Income Guidelines that were in effect for the date(s) of service, and verify that the patient's income and family size on the date(s) of service were correctly calculated according OAC 5101:3-2-07.17. MAR 1 5 2010

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10. Request a list of pending-Medicaid accounts from Hospital. Verify that no accounts that have been approved for Medicaid were included in any log or Schedule F entry. !

11. The external reviewer shall issue a review report to the hospital.

Hospital Response to External Reviewer Report

The hospital must respond to the external reviewer with a written report which includes a course of corrective action taken by the hospital.

Re-verification of Schedule F Changes

Any hospital that submits an amended cost report that includes changes to data reported on Schedule F shall be required to have an independent CPA re-verify the data reported on Schedule F. The external reviewer shall, at a minimum, perform the data verification as follows:

1. When making wholesale changes, including reassigning amounts between write-off categories, the entire Schedule F data shall be reviewed as specified in step 5.

2. If only new accounts are added and no other changes to Schedule F are made, then the CPA shall select and review at least 5% of new accounts from each category in accordance with the review Procedures steps 6 through 9. If the number of accounts to be reviewed under the 5% criteria exceeds the original sample size, then the entire Schedule F data shall be reviewed as specified in step 5.

External Data Validation Report

Each hospital shall retain all Schedule F data validation review reports for every cost report year, including recertification review reports and hospital responses to auditor reports, for a period of three years, and shall make such reports available to the department upon request, within three business days of such request.

GENERAL INSTRUCTIONS (APPLIES TO ALL OF SECTION I):

Only discharges/visits and charges for hospital services may be included in Schedule F. Include only “Basic, medically necessary hospital level services” which are considered services in Appendix A of rule 5101:3-2-02 of the Ohio Administrative Code. Do not include charges related to physicians’ services, transportation services, or take-home pharmacy items, and do not include visits to free standing clinics or surgery centers that are not hospital based. Do not include any portion of a patient account for a Medicaid recipient, regardless of whether the recipient is enrolled in an HMO or Medicaid fee-for-service. Do not include discharge/visits and charges that have been written off as Medicare bad debts.

Report uncompensated care information for patients with insurance in Column 1. Report uncompensated care information for patients without insurance in Column 2. Schedule F does not include a column for reporting total uncompensated care; it will be calculated by the department. Include any charges, inpatient discharges, and outpatient visits for patients eligible for “Hill-Burton” or covered by a local levy fund. Do not consider any Hill-Burton write-off or any payment by a local health care levy to be “insurance.”

In both Column 6 and 7 the amount reported in lines 8 through 15 must equal all payments you have either received or reasonably expect to receive from these patients or their insurers. For patients below poverty without insurance, rule 5101:3-2-07.17 of the Ohio Administrative Code requires that these patients receive care free of charge. There are very few circumstances which allow you to accept receipts for these accounts.

The data on uncompensated care for people on Disability Assistance in lines 8 and 12, and the data on uncompensated care for patients with family incomes below federal poverty guidelines in lines 9 and 13, may only include inpatient and outpatient accounts with discharge/visit dates that fall within your hospital's fiscal year. You must split-bill any outpatient accounts which cross these

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dates. Uncompensated care for patients with family incomes above federal poverty income guidelines may be included in lines 10 and 14 regardless of the service dates, so long as the date of the bad debt or charity care write-off fell within your hospital's fiscal year, and had not been previously written off.

SECTION I (UNCOMPENSATED CARE FOR ACUTE CARE HOSPITALS) Instructions for Column 1

COLUMN 1 Information in Column 1 should include data for patients who have received uncompensated care for some portion of their inpatient discharge or outpatient visit that was also covered by health insurance for the services provided.

GROSS INPATIENT CHARGES

Line 8: Total DA Charges for Patients with Insurance - INPATIENT Enter the gross charges for inpatient discharges by eligible Disability Assistance recipients, who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 9: Total UC Charges for Patients Below 100% with Insurance - INPATIENT

Enter the gross charges for inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, during your hospital’s fiscal year.

Line 10: Total UC Charges for Patients Above 100% with Insurance - INPATIENT

Enter the gross charges for inpatient discharges for patients with family incomes above the federal poverty income guidelines, and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital’s fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 11: Total Uncompensated Care Charges for Patients with Insurance - INPATIENT Enter the total of lines 8 through 10.

GROSS OUTPATIENT CHARGES

Line 12: Total DA Charges for Patients with Insurance — OUTPATIENT Enter the gross charges for outpatient visits by eligible Disability Assistance recipients, who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 13: Total UC Charges for Patients Below 100% with Insurance — OUTPATIENT

Enter the gross charges for outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 14: Total UC Charges for Patients Above 100% with Insurance — OUTPATIENT

Enter the gross charges for outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of The Ohio Administrative Code, who had some form of insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any other state can not be included of Schedule F.

Line 15: Total Uncompensated Care Charges for Patients with Insurance — OUTPATIENT Enter the total of lines 12 through 14.

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Line 16: Total DA Inpatient Discharges for Patients with Insurance Enter the number of inpatient discharges for Disability Assistance patients who also had some form of insurance for the services delivered during your hospital's fiscal year.

Line 17: Total UC Inpatient Discharges for Patients Below 100% with Insurance

Enter the number of inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the service delivered, during your hospital's fiscal year.

Line 18: Total UC Inpatient Discharges for Patients Above 100% with Insurance

Enter the number of inpatient discharges for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of The Ohio Administrative Code, which had some form of insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 19: Total UC Inpatient Discharges for Patients with Insurance Enter the total of lines 16 through 18.

OUTPATIENT VISITS

Line 20: Total DA Outpatient Visits for Patients with Insurance Enter the number of outpatient visits for Disability Assistance patients who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 21: Total UC Outpatient Visits for Patients Below 100% with Insurance

Enter the number of outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the service delivered, during your hospital’s fiscal year.

Line 22: Total UC Outpatient Visits for Patients Above 100% with Insurance i Enter the number of outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which had some form of insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 23: Total UC Outpatient Visits for Patients with Insurance i Enter the total of lines 20 through 22. :

Instructions for Column 2

COLUMN 2 Information in Column 2 should include data for patients who have received uncompensated care and do not have any insurance for the services provided.

GROSS INPATIENT CHARGES

Line 8: Total DA Charges for Patients without Insurance — INPATIENT Enter the gross charges for inpatient discharges by eligible Disability Assistance recipients, who did not have insurance for the services delivered, during your hospital's fiscal year.

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Line 9: Total UC Charges for Patients Below 100% without Insurance — INPATIENT

Enter the gross charges for inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 10: Total UC Charges for Patients Above 100% without Insurance — INPATIENT

Enter the gross charges for inpatient discharges for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, who did not have insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital’s fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 11: Total Uncompensated Care Charges for Patients without Insurance — INPATIENT Enter the total of lines 8 through 10.

GROSS OUTPATIENT CHARGES

Line 12: Total DA Charges for Patients without Insurance — OUTPATIENT Enter the gross charges for outpatient visits by eligible Disability Assistance recipients, who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 13: Total UC Charges for Patients Below 100% without Insurance — OUTPATIENT

Enter the gross charges for outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 14: Total UC Charges for Patients Above 100% without Insurance ~ OUTPATIENT

Enter the gross charges for outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, who did not have insurance for the services delivered, but were either unable or unwilling to pay for a Portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 15: Total Uncompensated Care Charges for Patients without Insurance — OUTPATIENT Enter the total of lines 12 through 14.

INPATIENT DISCHARGES

Line 16: Total DA Inpatient Discharges for Patients without Insurance Enter the number of inpatient discharges for Disability Assistance patients who did not have insurance for the services delivered during your hospital's fiscal year.

Line 17: Total UC Inpatient Discharges for Patients Below 100% without Insurance

Enter the number of inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who did not have insurance for the service delivered, during your hospital’s fiscal year.

Line 18; Total UC Inpatient Discharges for Patients Above 100% without Insurance

Enter the number of inpatient discharges for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which did not have insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any other state cannot be included.

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Page 21 of 51

Line 19: Total UC Inpatient Discharges for Patients without Insurance Enter the total of lines 16 through 18.

OUTPATIENT VISITS

Line 20: Total DA Outpatient Visits for Patients without Insurance Enter the number of outpatient visits for Disability Assistance patients who did not have insurance for the i services delivered, during your hospital’s fiscal year. i

Line 21: Total UC Outpatient Visits for Patients Below 100% without Insurance

Enter the number of outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who did not have insurance for the service delivered, during your hospital’s fiscal year.

Line 22: Total UC Outpatient Visits for Patients Above 100% without Insurance

Enter the number of outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which did not have insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F. H

Line 23: Total UC Outpatient Visits for Patients without Insurance Enter the total of lines 20 through 22.

Instructions for Column 3 COLUMN 3 Column 3 includes the Medicaid inpatient and outpatient cost to charge ratios for your hospital.

Lines 8, 9, 10, and 11; Inpatient Cost to Charge Ratio : Divide the sum of the values in column 3, line 101, of Schedule D and column 3, line 101, of Schedule I by the : sum of the values in column 2, line 101, of Schedule D and column 2, line 101, of Schedule I to calculate the

inpatient cost to charge ratio.

Lines 12, 13, 14, and 15: Outpatient Cost to Charge Ratio

Divide the sum of the values in column 5, line 101, of Schedule D and column 5, line 101, of Schedule I by the sum of the values in column 4, line 101, of Schedule D and column 5, line 101, Schedule I to calculate the ' outpatient cost to charge ratio. . i

Instructions for Columns 4 and 5 Calculation of Uncompensated Care Costs for Patients with Insurance

Lines 8 through 15: Column 4

Multiply the value in column 1 by the value in column 3 for each line and subtract the value in column 6. i

Lines 8 through 15: Column 5 \ Multiply the value in column 2 by the value in column 3 for each line and subtract the value in column 7.

Instructions for Column 6

COLUMN 6 Information in Column 6 should include data for patients who have received uncompensated care for some portion of their inpatient discharge or outpatient visit that was also covered by health insurance for the services provided.

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INPATIENT RECEIPTS

Receipts are to include ALL payments received or reasonably expect to receive on account, from patients or their insurers.

Line 8; Total DA Receipts for Patients with Insurance — INPATIENT i Enter the receipts for inpatient discharges by eligible Disability Assistance recipients, who also had some form ' of insurance for the services delivered, during your hospital's fiscal year. j

Line 9: Total UC Receipts for Patients Below 100% with Insurance — INPATIENT

Enter the receipts for inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, during i your hospital’s fiscal year.

Line 10: Total UC Receipts for Patients Above 100% with Insurance — INPATIENT

Enter the receipts for inpatient discharges for patients with family incomes above the federal poverty income guidelines, and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 11: Total Inpatient Uncompensated Care Receipts for Patients with Insurance — INPATIENT i Enter the total of lines 8 through 10. :

OUTPATIENT RECEIPTS i Receipts are to include ALL payments received or reasonably expect to receive on account, from patients or i their insurers. 5

Line 12: Total DA Receipts for Patients with Insurance — OUTPATIENT Enter the receipts for outpatient visits by eligible Disability Assistance recipients, who also had some form of \ insurance for the services delivered, during your hospital's fiscal year. i

Line 13: Total UC Receipts for Patients Below 100% with Insurance — OUTPATIENT

Enter the receipts for outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 14: Total UC Receipts for Patients Above 100% with Insurance — OUTPATIENT

Enter the receipts for outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of The Ohio Administrative Code, who had some form of insurance for the services delivered, but were either unable or : unwilling to pay for a portion of the bill and which were written off during your hospital's fiscal year. : Recipients of Medicaid in any other state can not be included of Schedule F. i

Line 15: Total Uncompensated Care Receipts for Patients with Insurance — OUTPATIENT H Enter the total of lines 12 through 14. t

UNDUPLICATED INPATIENT DISCHARGES

Line 16: Total DA Unduplicated Inpatient Discharges for Patients with Insurance Enter the number of unduplicated inpatient discharges for Disability Assistance patients who also had some form of insurance for the services delivered during your hospital's fiscal year.

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Line 17: Total UC Unduplicated Inpatient Discharges for Patients Below 100% with Insurance Enter the number of unduplicated inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3- 2-07.17 of the Ohio Administrative Code and who had some form of insurance for the service delivered, during your hospital’s fiscal year.

Line 18: Total UC Unduplicated Inpatient Discharges for Patients Above 100% with Insurance Enter the number of unduplicated inpatient discharges for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of The Ohio Administrative Code, which had some form of insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 19: Total UC Unduplicated Inpatient Discharges for Patients with Insurance Enter the total of lines 16 through 18.

UNDUPLICATED OUTPATIENT VISITS

Line 20: Total DA Unduplicated Outpatient Visits for Patients with Insurance

Enter the number of unduplicated outpatient visits for Disability Assistance patients who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 21: Total UC Unduplicated Outpatient Visits for Patients Below 100% with Insurance

Enter the number of unduplicated outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3- 2-07.17 of the Ohio Administrative Code and who had some form of insurance for the service delivered, during your hospital's fiscal year.

Line 22: Total UC Unduplicated Outpatient Visits for Patients Above 100% with Insurance

Enter the number of unduplicated outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which had some form of insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 23: Total UC Unduplicated Outpatient Visits for Patients with Insurance Enter the total of lines 20 through 22.

Instructions for Column 7

COLUMN 7 Information in Column 7 should include data for patients who have received uncompensated care and do not have any insurance for the services provided.

INPATIENT RECEIPTS Receipts are to include ALL payments received or reasonably expect to receive on account, from patients or their insurers.

Line 8: Total DA Receipts for Patients without Insurance — INPATIENT Enter the receipts for inpatient discharges by eligible Disability Assistance recipients, who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 9: Total UC Receipts for Patients Below 100% without Insurance — INPATIENT

Enter the receipts for inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who did not have insurance for the services delivered, during your hospital's fiscal year.

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Line 10: Total UC Receipts for Patients Above 100% without Insurance — INPATIENT

Enter the receipts for inpatient discharges for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, who did not have insurance for the services delivered, but were either unable or unwilling to pay for a Portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 11: Total Uncompensated Care Receipts for Patients without Insurance — INPATIENT Enter the total of lines 8 through 10.

OUTPATIENT RECEIPTS

Receipts are to include ALL payments received or reasonably expect to receive on account, from patients or their insurers.

Line 12: Total DA Receipts for Patients without Insurance — OUTPATIENT Enter the receipts for outpatient visits by eligible Disability Assistance recipients, who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 13: Total UC Receipts for Patients Below 100% without Insurance — OUTPATIENT

Enter the receipts for outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who did not have insurance for the services delivered, during your hospital’s fiscal year.

Line 14: Total UC Receipts for Patients Above 100% without Insurance — OUTPATIENT

Enter the receipts for outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, who did not have insurance for the services delivered, but were either unable or unwilling to pay for a Portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 15: Total Uncompensated Care Receipts for Patients without Insurance — OUTPATIENT Enter the total of lines 12 through 14.

UNDUPLICATED INPATIENT DISCHARGES

Line 16: Total DA Unduplicated Inpatient Discharges for Patients without Insurance Enter the number of unduplicated inpatient discharges for Disability Assistance patients who did not have insurance for the services delivered during your hospital's fiscal year.

Line 17; Total UC Unduplicated Inpatient Discharges for Patients Below 100% without Insurance Enter the number of unduplicated inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3- 2-07.17 of the Ohio Administrative Code and who did not have insurance for the service delivered, during your hospital's fiscal year.

Line 18: Total UC Unduplicated Inpatient Discharges for Patients Above 100% without Insurance Enter the number of unduplicated inpatient discharges for patients with family incomes above the federal Poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which did not have insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any other state cannot be included.

Line 19: Total UC Unduplicated Inpatient Discharges for Patients without Insurance Enter the total of lines 16 through 18.

MAR 1 5 2010

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Page 25 of 51 UNDUPLICATED OUTPATIENT VISITS

Line 20: Total DA Unduplicated Outpatient Visits for Patients without Insurance Enter the number of unduplicated outpatient visits for Disability Assistance patients who did not have insurance for the services delivered, during your hospital’s fiscal year.

Line 21: Total UC Unduplicated Outpatient Visits for Patients Below 100% without Insurance Enter the number of unduplicated outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3- 2-07.17 of the Ohio Administrative Code and who did not have insurance for the service delivered, during your hospital's fiscal year.

Line 22: Total UC Unduplicated Outpatient Visits for Patients Above 100% without Insurance Enter the number of unduplicated outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which did not have insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 23; Total UC Unduplicated Outpatient Visits for Patients without Insurance Enter the total of lines 20 through 22.

SECTION II (FREE-STANDING PSYCHIATRIC HOSPITAL INFORMATION)

LINE 24 Only free-standing psychiatric hospitals should complete this section.

Column 1: Payments from Insurance Enter payments received for psychiatric hospital inpatient services billed to and received from all sources other than the self-pay revenues in Column 2 and Ohio Medicaid payments reported on Schedule H.

Column 2: Payments from Self-Pay

Enter payments received for psychiatric hospital inpatient services billed to and received from either the person who received inpatient psychiatric services or the family of the person that received inpatient psychiatric service.

Column 3: Charges for Charity Care

Enter the total charges for psychiatric hospital services provided to indigent patients. This includes charges for services provided to individuals who do not possess health insurance for the services provided. However, this does not include bad debts, contractual allowances or uncompensated care costs rendered to patients with insurance where the full cost of service was not reimbursed because of per diem caps or coverage limitations.

Column 4: Government Cash Subsidies Received Enter the amount of cash subsidies received directly from state and local governments for psychiatric hospital inpatient services.

Column 5: Uncompensated Care Costs for Patients with Insurance Enter the psychiatric hospital inpatient costs for individuals that have insurance coverage for the service provided, but full reimbursement was not received due to per diem caps or coverage limitations.

Column 6: Medicaid Days Provided to Medicaid Recipients Age 21 and Under Enter the total psychiatric hospital inpatient days provided to Ohio Medicaid recipients age 21 and under who were discharged during the hospital’s fiscal year.

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Column 7: Medicaid Days Provided to Medicaid Recipients Age 22 to Age 64 Enter the total psychiatric hospital inpatient days provided to Ohio Medicaid recipients age 22 to age 64 who were discharged during the hospital's fiscal year.

Column 8: Medicaid Days Provided to Medicaid Recipients Age 65 and Over Enter the total psychiatric hospital inpatient days provided to Ohio Medicaid recipients age 65 and over who were discharged during the hospital's fiscal year.

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SCHEDULE G

TITLE XIX CAPITAL RELATED COST REIMBURSEMENT DRG EXEMPT HOSPITALS SHOULD NOT COMPLETE THIS SCHEDULE.

Column 1 Lines 25-34 and 37-97 - For each revenue center, transfer the total charges from Schedule B, column 4, lines 25 through 34, and 37 through 97.

lu Lines 25-34 and 37-97 - For each revenue center, enter the "old" capital related cost from Worksheet B, Part II, column 25. The total of this column should match Worksheet B, Part II, column 25, line 95.

Column 3 Lines 25-34 and 37-97 - For each revenue center, enter the "new" capital related cost from Worksheet B, Part III, column 25. The total of this column should match Worksheet B, Part III, column 25, line 95.

Column 4 Lines 25-34 and 37-97 - Enter the sum of columns 2 and 3.

Column 5 Lines 25-34 and 37-97 - Divide column 4 by column 1. Enter the result rounded to six decimal places.

Column 6 Lines 25-34 and 37-97 - Enter the charge amounts from Schedule D, column 2.

Column 7 Lines 25-34 and 37-97 - For each revenue center, multiply column 6 by the corresponding ratio in column 5 and enter the result rounded to the nearest dollar.

Line 102 - Multiply the capital add-on rates in effect for the cost reporting period by the total number of XIX inpatient discharges on Schedule C-1, columns 2 and 3, line 40.

Columns 1-7 Line 35 - Enter the total of lines 25 through 34.

Line 98 - Enter the total of lines 37 through 97. Line 101 - Enter the total of lines 35 and 98.

Column 7 Line 103 - Enter the result of line 102 less line 101.

MAR 1 5 2016

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SCHEDULE H

SETTLEMENT SUMMARY SectionI © INPATIENT SERVICES

Line 1, columns 1-3 - Transfer amounts from Schedule D, column 3, line 101; Schedule D-1, column 9, line 101; and Schedule D, column 9, line 101, into the appropriate column.

Line 2, columns 1-3 - Enter am id by the program for services rendered to eligible program patien during the reporting period. Do not include payments received under the Hospital Care Assurance or UPL programs. In lud in column 1 DR’ lant servi ind in

Line 3, columns 1-3 - Enter the amount due from the program (based upon the reimbursement rate in effect when the service was rendered) for services rendered to eligible recipients during the reporting period for which reimbursement has not been received.

Line 4, columns 1-3 - Enter amounts received or receivable from other payers for services rendered to eligible program patients during the reporting period.

Line 5, columns 1-3 - Enter GROSS UPL payments received for discharges occurring during this reporting period.

Line 6, column 1 - Enter amount due Program/(Provider), using the opposite sign, from Schedule G, column 7, line 103. DRG-exempt and out-of-state hospitals, enter 0.

Line 7, columns 1-3 - Enter the sum of lines 2 through 6.

Line 8, columns 1-3 - Transfer amounts from Schedule D, column 2, line 101; Schedule D-1, column 8, line 101; and Schedule D, column 8, line 101, into the appropriate column.

In-State and DRG Exempt Hospitals move to Section II, line 10. DRG Out-of-State Hospitals complete line 9 before moving to Section II, line 10.

Line 9, column 1 - Enter the result of line 7 less line 8. If the result is negative, enter 0.

CONTINUE TO SECTION IT

ion IT OUTPATIENT SERVICES

Line 10, columns 1-2 - Transfer amounts from Schedule D, column 5, line 101 and Schedule D-1, column 11, line 101 into the appropriate columns.

Line 11, columns 1-2 - Enter the amount paid by the program for services rendered to eligible program patients during the reporting period.

Do Not Include amounts paid by the programs for the following items:

1. Services billed under the At Risk Pregnancy program. 2. Amounts paid under the Hospital Care Assurance Program. 3. Laboratory services with the exception of column 2 amounts which should include Title V payments for Outpatient Radiology and Laboratory services. MAR 1 5 2010

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Line 12, columns 1-2 - Enter the amount due from the program (based upon the reimbursement rate in effect when the service was rendered) for services rendered to eligible recipients during the reporting period for which reimbursement has not been received.

Line 13, columns 1-2 - Enter amounts received or receivable from other payers for services rendered to eligible program patients during the reporting period.

Line 14, columns 1-2 - LEAVE BLANK, This line is for the use of ODJFS. Line 15, columns 1-2 - Enter the sum of lines 10 through 14.

Line 16, columns 1-2 - Enter amounts from Schedule D, column 4, line 101 and Schedule D-1, column 10, line 101.

In-State and DRG Exempt Hospitals move to Section III, line 20. DRG Out-of-State Hospitals complete lines 17 thru 19 before moving to Section IV, line 28.

Line 17, column 1 - Subtract line 15 from line 10. Line 18 column 1 - Subtract line 16 from line 10. If the result is negative enter -0-. Line 19, column 1 - Subtract line 17 from line 18. ONTINUE Ti ON IV, LINE 28 Section III SETTLEMENT TEST THIS SECTION IS ONLY TO BE COMPLETED BY ALL DRG Exempt, and In-State DRG Hospitals

Line 20, columns 1-3 - Combine amounts from each column of Schedule H, Section I, line 1, and Section II, line 10 into the appropriate column.

Line 21, columns 1-3 - Combine amounts from each column of Schedule H, Section I, line 7, and Section II, line 15 into the appropriate column.

Line 22, columns 1-3 - Combine amounts from each column of Schedule H, Section I, line 8, and Section II, line 16 into the appropriate column.

Line 23, column 1 - Enter -0-. DRG-exempt hospitals, subtract line 21 from line 20. Line 23, columns 2 and 3 - Subtract line 21 from line 20.

Line 24, column 1 - Enter -0-. DRG-exempt hospitals, subtract line 22 from line 20. If the result is negative, enter -0-.

Line 24, columns 2 and 3 - Subtract line 22 from line 20. If the result is negative, enter -0-.

Line 25, column 1 - Enter the result of line 21 less line 22. If the result is negative, enter 0. DRG-exempt hospitals, subtract line 23 from line 24.

Line 25, columns 2 and 3 - Subtract line 23 from line 24. SectionIV PROGRAM(S) SUMMARY

Line 26, columns 1-3 — In-State DRG and DRG Exempt hospitals enter the amounts from Schedule H, Section III, line 25. Out-of-State DRG hospitals enter combined settlement amounts from Schedule H, Section I, line 9 and Schedule H, Section II, line 19. ’ TN No. 09-027 Approval patelAR 1 5 2010 JFS 02930-I (Rev. 4/2009) SUPERSEDES ;

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Line 27, column 1 - Enter the amount from Schedule G, column 7, line 103. DRG-exempt hospitals, enter 0.

Line 29, columns 1-3 - Enter the sum of lines 26 and 27.

MAR 1 5 2010 TN No. 09-027 Approval Date:

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SCHEDULE I

TITLE XIX HMO COST CALCULATIONS

OUT-OF-STATE HOSPITALS SHOULD NOT COMPLETE THIS SCHEDULE. SECTION I

Column 1 Lines 25-33 and 37-97 - Enter the ratio from Schedule B, column 5 for each revenue center on the corresponding lines.

Column 2 Lines 25-33 and 37-97 - Enter the charges for Title XIX covered inpatient services rendered during the reporting period.

Column 3 Lines 25-33 and 37-97 - Multiply the charges in column 2 by the corresponding ratio in column 1. Enter the result rounded to the nearest dollar.

Column 4 Lines 25-33, 37-40, and 45-97 - Enter the charges for Title XIX covered outpatient services. Do not include charges for Outpatient Laboratory Services.

Column 5 Lines 25-33, 37-40, and 45-97 - Multiply the charges in column 4 by the corresponding ratio in column 1. Enter the result rounded to the nearest dollar.

Column 6 — This column is reserved.

Column 7 Lines 25-33 and 37-97 - Enter the ratio from Schedule G, column 5, for each revenue center on the corresponding line.

Column 8 Lines 25-33 and 37-97 - Multiply the charges in column 2 by the corresponding ratio in column 7. Enter the result rounded to the nearest dollar.

Line 102 - Multiply the capital add-on rates in effect for the cost reporting period by the total number of Medicaid HMO inpatient discharges on Schedule C-1, columns 7 and 8, line 40.

Columns 2-8 Line 35 - Enter the total of lines 25 through 33.

Line 98 - Enter the total of Lines 37 through 97.

Line 101 - Enter the total of lines 35 and 98.

SECTION II

HMO inpatient encounters should be counted as the number of HMO Inpatient discharges and the number of

total inpatient days associated with the reported discharges, for which a hospital was paid and/or expects to receive payment.

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Attachment 4.19 - A

Page 32 of 51 HMO Outpatient encounters should be counted as the number of HMO Outpatient claims for which a hospital was paid and/or expects to receive payment. Series accounts/cycle bills should be counted as 1 visit per claim (not the number of dates of service on that claim). Line 103, column 2 - Enter the total XIX inpatient HMO days Schedule C-2, Column 2, Line 35. Line 103, column 4 - Enter the total XIX outpatient HMO visits. Line 104, column 2 - Enter the total facility inpatient HMO days. Line 104, column 4 — Enter the total facility outpatient HMO visits.

Line 105, column 2 - Enter the total XIX inpatient HMO discharges Schedule C-1, column 7, line 40 plus Schedule C-1, column 8, line 40.

Line 106, column 2 - Enter the total facility inpatient HMO discharges. Line 107, column 2 - Enter the total XIX inpatient HMO payments.

Line 107, column 4 — Enter the total XIX outpatient HMO payments.

MAR 1 § 2010

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Attachment 4.19 - A Page 33 of 51

Ohio Department of Job and Family Services HOSPITAL COST REPORT STATE FISCAL YEAR 2009 CERTIFICATION BY OFFICER OF HOSPITAL

In accordance with current Medicaid regulations (42CFR, 455.18, 455.19), all cost reports must contain the following:

This is to certify that the foregoing information is true, accurate, and complete.

I understand that payment of this Medicaid claim will be from Federal and State funds, and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws.

Thereby certify that I have read the above statement and that I have examined the accompanying cost report supporting schedules prepared for:

Provider Name [Medicaid Number]National Provider Identifier Street Address Federal ID Number City, State and Zip Code Medicare Provider Number(s)

for the cost reporting period beginning and ending and that to the best of

my knowledge and belief, it is a true, correct, and complete statement prepared from the books and records of the provider(s) in accordance with applicable instructions and regulations including independent certification of Schedule F, and the accuracy of the OBRA Survey, except as noted.

Signature of Officer or Administrator of Provider(s) Date of Signature

Print or Type Name. Title

Name of Individual Report Was Prepared By Title

IName of Person to Contact Regarding Report Tithe i Telephone Number (Include Area Code & Extenstion (if applicable)

MAR 1 5 2010

TN No. 09-027 Approval Date:

SUPERSEDES : JFS 02930 (Rev. 4/2009) }

TN No. 08-009 Effective Date: 11-30-2009

Attachment 4.19 - A Page 34 of 51

OBRA SURVEY

Medicaid programs must, on an annual basis, determine whether hospitals which receive disproportionate share Payments under Medicaid meet certain federally-mandated requirements. For instance, urban non-children's hospitals which receive disproportionate share payments and which offer non-emergency obstetrical services must have at least two obstetricians on staff who have agreed to service Medicaid patients. Rural hospitals which offer non-emergency obstetrical services must have at least two physicians (not necessarily obstetricians) who have agreed to provide obstetrical services to Medicaid recipients in order to receive Medicaid disproportionate share payments. A related requirement is that states must provide disproportionate share payments to hospitals with a low-income utilization rate that exceeds 25 percent.

Complete Section A and Section B for your facility for this cost reporting period.

Section A YES | NO _| N/A 1 Does your hospital predominantly serve patients less than 18 years of age? (If answer to this question is oOlo Yes, please proceed to Section B.)

2 As of December 22, 1987, did your hospital offer non-emergency obstetric services to the general ololo Population? (If answer to this question is No, please Proceed to Section B, if Yes answer question 3.)

3 Does your hospital currently offer non-emergency obstetric services to the general population? (If answer to Ololo this question is Yes, please proceed to Section B.)

4 Answer the one question below appropriate to your hospital. If your hospital is deemed a rural hospital for purposes of Medicare reimbursement, answer question (a). If your hospital is an urban hospital for purposes of Medicare reimbursement, answer question (b).

a Rural: Does your hospital have at least two physicians (may or may not be obstetricians) with staff Privileges who have agreed to provide non-emergency obstetric services to Medicaid recipients? If, O| OO you responded No, please explain below.

b Urban: Does your hospital have at least two obstetricians with staff privileges who have agreed to provide non-emergency obstetric services to Medicaid recipients? If you responded No, please Oo}; OJO explain below.

Section B The following section should be completed by hospitals to determine if a low-income utilization rate (as described below) which exceeds 25% exists.

“Low-income utilization rate" means, according to federal law, the sum of (1) and (2) below: (1) the fraction, expressed as a percentage: (a) the numerator of which is the sum for a period of Medicaid (Ohio only) revenues (payments including HMO payments

for patient services plus the amount of cash subsidies (including HCAP and UPL payments) for patient services received directly from state and local governments.

(b) the denominator of which is the total patient services revenue -- including such cash subsidies -- for the period. (2) the fraction, expressed as a percentage: (a) the numerator of which is the total (gross) hospital inpatient charges in a period attributable to charity care (not

including contractual allowances and discounts and bad debts) less the portion of any subsidies received in the period from state and local governments reasonably attributed to inpatient hospital services.

(b) the denominator of which is total (gross) hospital inpatient charges in the period.

Provide the following information from your financial records:

Fraction 1 Medicaid Revenues: Plus: Government Cash Subsidies: ] Fraction (1) i Total patient revenues including cash subsidies: C7] | ' Fraction 2 Total hospital inpatient charges for charity care (not including allowances, discounts and bad debts): Less: Government cash subsidies: ] Fraction (2)

Total inpatient charges: CL] CY Sum of Fraction (1) and (2) expressed as a percent:[ R15 2000

TN No. 09-027 Approval bard! SUPERSEDES 5FS 02930 (Rev. 4/2008) TN No. 08-009 Effective Date: 11-30-2009

Attachment 4.19 - A

Page 35 of 51

SFY 2009 INPATIENT BILLING CODE ALLOCATION

UB-92 Revenue Center Codes

25. Adult & Pediatric

001, 100, 110-113, 116, 117, 119-123, 126, 127, 129-133, 136, 137, 139, 150-153, 156, 157, 159, 160, 164, 169, 206, 214, 230, 232, 239, 240-243, 249

25a. Distinct Part Psychiatric

114, 124, 134, 154

25b. Distinct Part Rehabilitation

118, 128, 138, 158

26. Intensive Care

200, 201-204, 208, 209, 233

27. Coronary Care

210-213, 219, 234

28. Burn Unit 207 29. Surgical Intensive Care 204 30. Other Special Care *

31. Nursery Intensive Care 174

33. Nursery

170-173, 179, 231

37. Operating Room

360-362, 367, 369

37a. Ambulatory Surgery 490, 499 37b. Cast Room 700, 709 37c. Treatment or Observation Room 760-762, 769 38. Recovery Room 710, 719

39. Delivery & Labor Room

720-724, 729

40. Anesthesiology 370-372, 379

41. Radiology - Diagnostic 320-324, 329, 400, 401, 403, 409, 790, 799, 920 41a. CAT Scan 350-352, 359

41b. Ultrasound 402

41c. PET Scan 404

41d. MRI 610-612, 614-616, 618, 619

42. Radiology - Therapeutic 330-333, 335, 339

43. Radioisotope / Nudear Medicine 340-342, 349

44. Laboratory 300-302, 304-307, 309-312, 314, 319, 921, 923-925, 929 44a. Oncology 280, 289

46. Whole Blood & Blood Components 380-387, 389

47. Blood Processing, Storing & Transfusion {390, 391, 399

48. Intravenous Therapy 260-264, 269

49. Respiratory Therapy 410, 412, 413, 419

49a. Pulmonary Function 460, 469

50. Physical Therapy 420-424, 429, 530, 531, 539, 922, 940, 942, 949, 952 50a. Cardiac Rehab 943

51. Occupational Therapy 430-434, 439

52. Speech & Hearing Services 440-444, 449

52a. Audiology 470-472, 479

53. Electrocardiology 480, 482, 483, 489, 730-732, 739

53a. Cardiac Catheterization 481

54. Electroencephalography 740, 749

55. Medical Supplies 270-272, 274-276, 278, 279, 291, 621- 623 56. Pharmacy 250-252, 254, 255, 257-259, 634, 635, 637 '57. Renal Dialysis 800-804, 809, 880-881, 889

58. Organ Acquisition 810-812, 819

59. Psychiatric/Psychological Services 900, 909, 910, 914-916, 918-919

60. Clinic 510-517, 519, 770, 771, 779

61. Emergency 450-452, 456, 459

62. Observation Beds *

69. Gastrointestinal Services 750, 759

70. * *

Please refer to OAC 5101:3-2-02 for a list of inpatient and outpatient covered services.

*Billing codes should be allocated into revenue centers as indicated above. Any deviation from the above must be designated

above to indicate where the billing codes were allocated, and why they were allocated differently than requested.

*Do not include observation bed costs and charges reported on line 62 of the JFS 2930 and HCFA 2552-96 in revenue center 37b.

*If one revenue center code is applicable to more than one revenue center, please show which revenue centers it was allocated to on the

following page

* Please list the revenue center codes allocated to these revenue centers.

JFS 02930 (Rev. 4/2009)

MAR 1 5 2010

TN No. 09-027 Approval Date: SUPERSEDES TN No. 08-009 Effective Date: 11-30-2009

SFY 2009 OUTPATIENT BILLING CODE ALLOCATION

Attachment 4.19 - A Page 36 of 51

UB-92 Revenue Center Codes

25. Adult & Pediatric 160, 164, 169

001, 110-113, 116, 117, 119,-123, 126, 127, 129-133, 136, 137, 139, 150-153, 156, 157, 159,

25a. Distinct Part Psychiatric 114, 124, 134, 154

25b. Distinct Part Rehabilitation 118, 128, 138, 158

26. Intensive Care

27. Coronary Care

28. Burn Unit

29. Surgical Intensive Care

30. Other Special Care

31. Nursery Intensive Care

33. Nursery 170, 171, 179

37. Operating Room 360, 361, 369

37a. Ambulatory Surgery 490, 499 37b. Cast Room 700, 709 37c. Treatment or Observation Room 760-762, 769 38. Recovery Room 710, 719 39. Delivery & Labor Room 720-724, 729 40. Anesthesiology 370-372, 379

41. Radiology - Diagnostic

320-324, 329, 400, 401, 403, 409, 790, 799, 920

41a. CAT Scan 350-352, 359

41b. Ultrasound 402

41c. PET Scan 404

4id. MRI 610-612, 614-616, 618, 619

42. Radiology - Therapeutic 330-333, 335, 339

43. Radioisotope / Nudear Medicine 340-342, 349

44. Laboratory 300-302, 304-307, 309-312, 314, 319, 921, 923-925, 929 44a. Oncology 280, 289 46. Whole Blood & Blood Components 380-387, 389

47. Blood Processing, Storing & Transfusion [390, 391, 399

48. Intravenous Therapy 260-264, 269 49. Respiratory Therapy 410, 412, 413, 419 49a. Pulmonary Function 460, 469

‘50. Physical Therapy

420-424, 429, 530, 531, 539, 922, 940, 942, 949, 952

50a. Cardiac Rehab 943 51. Occupational Therapy 430-434, 439 52. Speech & Hearing Services 440-444, 449

52a. Audiology 470-472, 479

53. Electrocardiology 480, 482, 483, 489, 730-732, 739

53a. Cardiac Catheterization 481

54. Electroencephalography 740, 749

55. Medical Supplies 270-272, 276, 278, 279, 621- 623

56. Pharmacy 250-252, 254, 255, 258, 259, 634, 635, 637

57. Renal Dialysis

820, 821, 829-831, 839-841, 849-851, 859, 880, 881, 889

58. Organ Acquisition

59. Psychiatric/Psychological Services 900, 909-911, 914-916, 918, 919, 944, 945

60. Clinic 510-517, 519, 770, 771, 779 61. Emergency 450-452, 456, 459

62. Observation Beds *

69. Gastrointestinal Services 750, 759

70. *

71. *

72. *

Please refer to OAC 5101:3-2-02 for a list of inpatient and outpatient covered services. Follow the same procedures as outlined on the Inpatient Billing Code Allocation Sheet

IFS 02930 (Rev. 4/2009)

MAR 1 5 2010

TN No. 09-027 Approval Date: SUPERSEDES TN No, 08-009 Effective Date: 11-30-2009

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OS Notification State/Title/Plan Number: Ohio 09-027 Type of Action: SPA Approval

Required Date for State Notification: | March 24, 2010

Fiscal Impact: FY 2010 $0

FY 2011 $0

Number of Services Provided by Enhanced Coverage, Benefits or Retained Enrollment: 0

Number of Potential Newly Eligible People: 0

Eligibility Simplification: No

Provider Payment Increase: No

Delivery System Innovation: No

Number of People Losing Medicaid Eligibility: No

Reduces Benefits: No

Effective for services on or after November 30, 2009, this amendment revises dates and filing requirements for the hospital cost report for reporting periods ending in State fiscal year 2009.

Other Considerations:

This plan amendment has not generated significant outside interest and we do not recommend the Secretary contact the governor.

Recovery Act Impact:

regarding 1) MOE; 2) local match; 3) prompt pay; 4) rainy day funds, and 5) eligible expenditures, the Regional Office believes that the State is not in violation of the Recovery Act requirements noted above.

CMS Contact:

Todd McMillion (608) 441-5344 National Institutional Reimbursement Team

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITIAL NUMBER: 0 9-027 2. STATE OHIO FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3· PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECTIVE DATE November 30, 2009 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN i:8J AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se orate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42 CFR part 441 - Subpart C; 42 CFR Part 441 - Subpart D; 42 CFR a. FFY 2009 $ 0 art 447 - Sub art C b. FFY 2010 $ 0 8. PAGE NUMBER OF THE PLAN SECTION OR ATIACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION 4.19-A Rule 5101:3-2-23 Cost Reports and Appendix OR ATIACHMENT (If Applicable): 10. SUBJECT OF AMENDMENT: Cost Reports 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITI AL 4.19-A Rule 5101:3-2-23 Cost Reports and Appendix ~ OTHER. AS SPECIFIED: Governor bu delegated signature authority to ODJFS Director. Director bas delegated signature authority to Medicaid Director 16. RETURN TO: 12. SIGNATURE OF STAT~CY OFJCI -1-3-. TYP __ E_D_N_AM--E: ___ _,_ ..... TRA--+-Y-=J=.'-P-'-L-O~U-C_K_--'..&L..=--1 Becky Jackson OHPfBureau of Health Plan Policy -----------S-T_A_T_E_M_E_D-IC-AID--D-IRE--C-TO-R--1 Ohio Department of Job and Family Services 14. TITLE: P.O. BOX 182709 15. DATE SUBMITTED: 17. DATE ltECEMm: IJ ;Lt/ 09 Columbus, Ohio 43218 J 11.D.iATE. APPllOYEO;... I ~-·S"-IO PLAN APPllOVSD- ONE COPY ATf. lt. £FF£CTIVEDATEOf APPllOVED~ · 2069 · Instructions on Back FORM CMS-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES C ~S7 Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26- 12 OrMEDICARE `A1 MMUS CROW Baltimore, Maryland 21244 -1850 Center for Medicaid, CHIP, and Survey & Certification (CMCS) Ms. Tracy Plouck, Deputy Director Office of Ohio Health Plans Ohio Department of Job and Family Services JUN 2. 4 2010 P.O. Box 182709 50 West Town Street, Suite 400 Columbus, Ohio 43218 RE: Ohio 09 -032 Dear Ms. Plouck: We have reviewed the proposed amendment to Attachment 4.19 -A ofyour Medicaid State plan submitted under transmittal number (TN) 09 -032. Effective for services on or after November 30, 2009, this amendment revises supplemental payments to children's hospitals for inpatient outliers and supplemental inpatient hospital upper limit payments for children's hospitals. We conducted our review of your submittal according to the statutory requirements at sections 1902(a)( 2), 1902(a)( 13), 1902(a)( 30), 1903(a), and 1923 of the Social Security Act and the implementing Federal regulations at 42 CFR 447 Subpart C. We are pleased to inform you that Medicaid State plan amendment 09 -032 is approved effective November 30, 2009. We are enclosing the HCFA -179 and the amended plan pages. If you have any questions, please call Todd McMillion at (608) 441 -5344. Sincerely, Riliot preocruri 4 _.-- Cindy Mann Director Center for Medicaid, CHIP, and Survey & Certification

STATE OF OHIO ATTACHMENT 4.19 -A Page 28 Supplemental Payments to Children's Hospitals for Inpatient Outliers A. Notwithstanding paragraph (CX5) of rule 5101:3 - 2 -07.9 of the Ohio Administrative Code, children's hospitals that meet the criteria in paragraphs (E)(1) and (EX2) of rule 5101:3 - 2 -07.9 ofthe Administrative Code, will be paid for each cost outlier claim made in fiscal years 2010 and 2011, an amount that is the product of the hospital's allowable charges and the hospital's Medicaid inpatient cost -to- charge ratio. The cost -to- charge ratio is based on the Medicaid charges as reported on the hospital's Medicaid cost report JFS 02930) and the costs attributable to Medicaid as calculated based on the proportion of Medicaid charges to total charges on the hospital's interim settled cost report as applied to the claim year. B. A Children's hospital shall cease being paid for a cost outlier claim under the methodology described in paragraph (A) on page 28 of Attachment 4.19 -A and revert to being paid for such a claim according to methodology in paragraph (A)(6) or (C)(5) of rule 5101:3 - 2 -07.9 ofthe Administrative Code, as applicable, when the difference between the total amount paid according to the methodology described in paragraph (A) on page 28 of Attachment 4.19 -A for such claims and the total amount the Director would have paid according to the methodology in paragraph (A)(6) or (C)(5) of rule 5101:3 - 2 -07.9 of the Administrative Code, as the applicable paragraph existed on June 30, 2007, for such claims, exceeds the amount available as described in paragraph (D) on page 28 ofAttachment 4.19 -A for the applicable fiscal year. C. Payments shall be made under paragraph (D) on page 29 ofAttachment 4.19 -A, Supplemental Inpatient Hospital Upper Limit Payments For Children's Hospitals, ifthe difference between the total amount the Director has paid according to the methodology in paragraph (A) on page 28 ofAttachment 4.19 -A for cost outlier claims and the total amount the Director would have paid according to the methodology in paragraph (A)(6) or (CX5) ofrule 5101:3 - 2 -07.9 of the Administrative Code for such claims, as the applicable paragraph existed on June 30, 2007, does not require the expenditure ofthe total amount available as described in paragraph (D) on page 28 of Attachment 4.19 -A for the applicable fiscal year. D. Up to $38.7 million in SFY 2010 and $31.6 million in FFY 2011 shall be used to pay the amounts described in paragraph (A) on page 28 of Attachment 4.19 -A. E. The source data for calculations described in paragraphs (A) on page 28 of Attachment 4.19 -A through (C) on page 28 of Attachment 4.19 -A will be based on claims paid for outliers during the prior state fiscal year. F. Payments will be made to children's hospitals on an annual basis, based upon children's hospitals' actual inpatient Medicaid fee - for - service outliers derived from actual Medicaid discharges paid during the prior state fiscal year and upon the difference between what each hospital would be paid according to the methodology described in paragraph (A) on page 28 of Attachment 4.19 -A the amount the hospital had been paid. G. Hospital payments made under this section shall not exceed the amount available as described in paragraph (D) on page 28 ofAttachment 4.19 -A for the applicable fiscal year nor, when combined with other payments made to private hospitals under the State plan, the limit specified in 42 CFR 447.272. Ifthe total funds that would be paid to all children's hospitals exceeds either of those amounts, then the amount paid to each children's hospital would be its proportion of the lesser of: the amount described by paragraphs (A) through (C) on page 29 of Attachment 4.19 -A; or the amount described in paragraph (D) on page 28 of Attachment 4.19 -A. Each hospital's proportion would be equal to the difference between the total amount the Director would pay according to the TN No 09-032 Approval Date: JUN 2 4 2010 Supersedes TN No. 07-009 Effective Date: 11 -30 -09

STATE OF OHIO ATTACHMENT 4.19 -A Page 29 methodology described in paragraph (A) for such claims minus the total amount the Director paid for such claims for that hospital divided by the sum ofthat amount for all children's hospitals. H. Hospital payments made under this section, when combined with other payments made under the State plan shall not exceed the limit specified in 42 CFR 447.271. The total funds that will be paid to each children's hospital will be included in the calculation ofdisproportionate share limits as described in rule 5101:3 - 2 -07.5 of the Ohio Administrative Code. Supplemental Inpatient Hospital Upper Limit Payments For Children's Hospitals A. For each Ohio hospital owned or operated by an entity other than a governmental entity, calculate the estimated amount that Medicare would have paid for an inpatient discharge if Medicare were paying the care for Medicaid consumers. a. Inpatient upper payment limit gap calculation for private hospitals excluding private free standing psychiatric hospitals. 1. Divide the total Medicare inpatient hospital payment by the hospital's Medicare inpatient hospital charges to calculate the hospital specific Medicare payment to charge ratio. 2. Multiply the hospital specific Medicare payment to charge ratio by Medicaid charges to calculate the estimated Medicare payment for Medicaid consumers. 3. For each private hospital, calculate the available payment gap by taking total estimated Medicare payment for Medicaid discharges as calculated in paragraph A)(2) and subtracting actual Medicaid payments. b. Inpatient upper payment limit gap calculation for private free standing psychiatric hospitals. 1. Identify inpatient Medicaid costs for each private free standing psychiatric hospitals. 2. Identify inpatient Medicaid payments for each private free standing psvchiatric hospitals 3. For each free standing private psychiatric hospital, calculate the inpatient upper payment limit gap by subtracting the amount tnparagraph (A)( b)( 2) from the amount in (A )( b)( 1). c. For all private hospitals, the sum of the amounts calculated in paragraph (A)( a)( 3) and A)( b)( 3) on page 29 of Attachment 4.19 -A. is the aggregate inpatient upper limit payment Rao for all private hospitals. B. The resulting amount calculated in paragraph (A) on page 29 of Attachment 4.19 -A will be in effect from the effective date ofthe state plan amendment through December 31 of that year, and from January 1 through December 31 ofeach year after. C. The source data for calculations described in this amendment will be based on cost reporting data described in rule 5101:3 - 2 -23 of the Ohio Administrative Code which TN No. 09 -032 Approval Date: JUN 2 4 2010 Supersedes TN No. 07 -009 Effective Date:_ 11 -30-09

STATE OF OHIO ATTACHMENT 4.19 -A Page 30 reflects the most recent completed interim settled Medicaid cost report (JFS 02930) for all hospitals, and the Medicare cost report (CMS 2552 -96) for the corresponding cost reporting period. D. Ifthe Supplemental Payments to Children's Hospitals for Inpatient Outliers do not require the expenditure ofthe amount described under paragraph (D) on page 28 of Attachment 4.19 -A for the supplemental outlier payments and available under the upper payment limit as described by paragraphs (A) on page 29 ofAttachment 4.19 -A through C) on page 29 ofAttachment 4.19 -A, the department would make additional supplemental payments to children's hospitals up to the lesser of the amount described in paragraph (D) on page 28 ofAttachment 4.19 -A or the amount described by paragraphs A) on page 29 of Attachment 4.19 -A through (C) on page 29 of Attachment 4.19 -A as follows: Payments will be made to children's hospitals on a annual basis, based upon children's hospitals actual inpatient Medicaid fee- for - service days derived from actual Medicaid discharges paid during the prior twelve -month period, subject to the provisions in paragraph (B) on page 29 ofAttachment 4.19 -A. Ifthe total funds that would be paid to all children's hospitals exceeds the aggregate upper payment limit for all private hospitals, then the amount paid to all children's hospitals will be limited to their proportion ofthe aggregate upper payment limit. E. Hospital payments made under this section, when combined with other payments made under the State plan shall not exceed the limit specified in 42 CFR 447.271. F. The total funds that will be paid to each children's hospital will be included in the calculation ofdisproportionate share limits as described in rule 5101:3 - 2 -07.5 ofthe Ohio Administrative Code. TN No. 9E132 Approval Date: JUN 2 4 2010 Supersedes TN No. 07 -009 Effective Date: 11 -30 -09

Attachment 4.19 - A DRAFT - NOT FOR FILING * * 5101:3 - 2 -53 Supplemental inpatient hospital payments for children's hospitals. This rule sets forth the methodology used to determine the supplemental inpatient hospital payments to children's hospitals required by Section 309.30. 13 309.30. 15 of Amended Substitute House Bill 4-44 1 of the 4? 128th General Assembly. A) Definitions. 1) " Children hospital ", for the purpose of this rule, means an Ohio hospital as defined in section 3702.51 of the Revised Code that is owned and operated by a private entity and is subject to prospective payment as described in rule 5101:3 - 2 -07.1 of the Administrative Code. 2) " Private hospital" means an Ohio hospital other than as defined in rules 5101:3- 2 - 50 and 5101:3 - 2 - 51 of the Administrative Code. 3) " Available inpatient payment gap" means the difference between what is estimated using the methodology described in paragraphs (C) and (D) of this rule that medicare would have paid for medicaid consumers and actual medicaid payments made in accordance with Chapter 5101:3 - 2 of the Administrative Code. 4) " Total medicaid inpatient payments" for each hospital means the amount paid by the medicaid program for services rendered to eligible medicaid patients, excluding supplemental payments, as reported on the medicaid cost report, as specified in paragraph (B) of this rule. 5) " Total medicaid inpatient discharges" means for each hospital the number of discharges from the facility for medicaid patients, as reported on the medicaid cost report, as specified in paragraph (B) of this rule. 6) " Total medicaid inpatient charges" means for each hospital the charges for covered medicaid inpatient services rendered, as reported on the medicaid cost report, as specified in paragraph (B) of this rule. 7) " Medicare inpatient payments for hospitals exempt from medicare diagneetie - diagnosis relaxed gnupsgrouv (DRG) payments and medicare inpatient payments for subproviders" means the inpatient payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. 8) " Medicare inpatient DRG payments" means the DRG payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. 9) " Medicare inpatient outlier payments" means the outlier payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. JUN 242010 TN No. 09-032 Approval Date: SUPERSEDES TN No. 07-009 Effective Date: 11-30- 2009

Attachment 4.19 - A DRAFT - NOT FOR FILING 10) " Medicare inpatient indirect medical education" means the indirect medical education adjustment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. 11) " Medicare inpatient disproportionate share payments" means the inpatient disproportionate share adjustment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule, 12) " Medicare inpatient hospital capital payments" means" the payment for inpatient program capital as reported on the medicare cost report, as specified in paragraph (B) of this rule. 13) " Medicare inpatient direct medical education" means the direct graduate medical education payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. 14) " Medicare inpatient hospital payments - other" means the sum of net organ acquisition cost, cost of teaching physicians, routine service other pass through costs, and ancillary service other pass through costs, as reported on the medicare cost report, as specified in paragraph (B) of this rule. 15) " Total medicare inpatient charges" means the amount of inpatient charges for each hospital and subprovider, as reported on the medicare cost report, as specified in paragraph (B) of this rule. 16) " Total medicaid days" means for each children's hospital the number of days reported from the facility for medicaid fee- for - service patients, as reported on the medicaid cost report, as specified in paragraph (B) of this rule. 17) " Program year" means the twelve -month period beginning on the first day of January and ending on the thirty -first day of December. 18) " Medicaid inpatient cost -to- charge ratio" means the historic medicaid inpatient cost -to- charge ratio applicable to a hospital as described in paragraph (B)( 2) of rule 5101:3 - 2 - 22 of the Administrative Code. B) Source data for calculations. Unless otherwise specified, the calculations described in this rule will be based on cost reporting data described in rule 5101:3 - 2 -23 of the Administrative Code that reflects the most recent completed interim settled medicaid cost report for all hospitals, and the medicare cost report for the corresponding cost reporting period. C) Calculation of available inpatient payment gap for private hospitals. JUN 2 42010 TN No. 09-032 Approval Date: SUPERSEDES TN No. 07-009 Effective Date: J1 -30 -2009

Attachment 4.19 - A DRAFT - NOT FOR FILING * * 1) Calculation of available inpatient payment gap forprivate hospitals that are not free - standing psychiatric hospitals. a) For each private hospital, calculate the total medicare inpatient payment by adding the amounts described inparagraphs (A)(7) to (A)( of this rule. b) For each private hospital, calculate the medicare payment -to- charge ratio by dividing the amount calculated in paragraph (C)(1)( a) of this rule by the total medicare inpatient charges as described in paragraph (A)( 15) of this rule. c) For each private hospital, calculate the total estimated medicare inpatient payment for medicaid inpatient discharges by multiplying the amount calculated in paragraph (C)(1)( b) of this rule by the total medicaid inpatient charges as described in paragraph (A)(6) of this rile. d) For each private hospital. calculate the available inpatient payment gap by taking total estimated medicare inpatient payments for medicaid inpatient discharges as calculated in paragraph (C)(1)( c) of this rule and subtracting actual total medicaid inpatient payments as described in paragraph (A)(4) of this rule. e) For each private hospital that as an available 'n tient payment gap greater than zero resulting from the calculations in paragraph (C)( 1)( d) of this rule. calculate the available per discharge supplemental inpatient hospital Payment amount by dividing the amount in paragraph (C)( 1)( d) of this rule by the amount in paragraph (A)(5) of this rule. 12) Calculation of available inpatient payment gap for private psychiatric hospitals PPH) subject to medicaid prospective payment as described in rule 5101:3- 2 - 07.8 of the Administrative Code and excluded from prospective payment under medicare, 42 C.F. R. 412.23( a) in effect as ofOctober 1, 2003. a) For each PPH described in this paragraph, "medicaid inpatient costs" means medicaid inpatient costs as reported on the medicaid cost report, as specified in paragraph (B) of this rule. fb) For each PPH described in this paragraph. "medicaid inpatient payments" means medicaid inpatient payments as reported on the medicaid cost report, as specified in paragraph (B) of this rule. lc) For each PPH described in this paragraph. "medicaid discharges" means medicaid discharges as reported on the medicaid cost report, as specified in paragraph (B) of this rule. JUN 2 42010 TN No. 09 -032 Approval Date: SUPERSEDES TN No. 07 -009 Effective Date: 11-30 -2004

Attachment 4.19 - A DRAFT -- NOT FOR FILING d) For each PPH described in this paragraph. calculate the available inpatient payment gap by subtracting the amount in paragraph (C)( 2)( b) of this rule from the amount in paragraph (C)( 2)( a) of this rule. e) For each PPH described in this paragraph that has an available inpatient payment gap greater than zero resulting from the calculations in paragraph(C)( 2)( d) of this rule, calculate the available per discharge supplemental inpatient hospital payment amount by dividing the amount in paragraph (C)( 2)( d) of this rule by the amount in paragraph (C)( 2)( c) of this rule. 3) For all private hospitals, sum the amounts calculated in paragraphs (C)( 1)( d) and C)( 2)( d) of this rule. This is the aggregate inpatient upper limit for all private hospitals. heap-kills D) For each supplemental payment made after the effective date of this rule, the resulting upper payment limit calculated in paragraph (C) of this rule will be in effect from the first day of January through the thirty -first day of December for each supplemental payment program year. E) Notwithstanding paragraph (C)(5) of rule 5101:3 - 2 -07.9 of the Administrative Code and except as provided in paragraph (F) of this rule, the director of the Ohio JUN 242010 TN No. 09-03 Approval Date: SUPERSEDES TN No. 07 -009 Effective Date: 11- 30-2009

Attachment 4.19 - A DRAFT - NOT FOR FILING department ofjob and family services (ODJFS) shall pay a children's hospital that meets the criteria in paragraphs (E)( 1) and (EX2) of rule 5101:3 - 2 -07.9 of the Administrative Code, for each cost outlier claim made in fiscal years 2008 -a1 -2009 2010 and 2011, an amount that is the product of the hospital's allowable charges and the hospital's medicaid inpatient cost -to- charge ratio. These payments shall be made as supplemental inpatient outlier payments as follows: 1) In July ofeach year after the effective date of the medicaid state plan amendment implementing this payment program, the director shall calculate for each eligible children's hospital the difference between the total amount the director would have paid according to the methodology in paragraph (E) of this rule for such claims for services incurred during the prior state fiscal year using the same cost -to- charge ratio as the ratio used to calculate cost outlier payments in accordance with rule 5101:3 - 2-07. 9 of the Administrative Code for services incurred during that time period and the total amount the director paid according to the methodology in paragraph (A)(6) or (C)(5) of rule 5101:3 - 2 -07.9 of the Administrative Code, as the applicable paragraph existed on June 30, 2007, for such claims as reflected in actual medicaid inpatient claims paid through the department's medicaid management information system (MMIS) in the prior state fiscal year. 2) If the sum of the amounts calculated in paragraph (E)(1) of this rule for all eligible children's hospitals is less than or equal to the available amount for each fiscal year as provided in Section 309.30. 13 309.30. 15 of Amended Substitute House Bill 449 1 of the 4t 128th General Assembly, then the supplemental inpatient outlier payment for each children's hospital shall be the amount calculated in paragraph (E)( 1) of this rule. Otherwise, the supplemental inpatient outlier payment for each children's hospital shall be the amount calculated in paragraph (F) of this rule. F) The director shall cease paying a children's hospital for a cost outlier claim under the methodology in paragraph (E) of this rule and revert to paying the hospital for such a claim according to methodology in paragraph (A)(6) or (C)(5) of rule 5101:3 - 2 -07.9 of the Administrative Code, as applicable, when the difference between the total amount the director would pay according to the methodology in paragraph (E) of this rule for such claims and the total amount the director paid according to the methodology in paragraph (A)(6) or (CX5) of rule 5101:3 - 2 -07.9 of the Administrative Code, as the applicable paragraph existed on June 30, 2007, for such claims, exceeds the available amount for each fiscal year as provided in Section - 309.30. I3309.30. 15 of Amended Substitute House Bill -1441 of the 4-2- 7th 128th - General Assembly. If the sum of the amounts calculated in paragraph (E)(1) of this rule for all eligible children's hospitals is greater than the available amount for each fiscal year as provided in Section 309.30. 13309.30. 15 of Amended Substitute House Bill 4491 of the 42 128th General Assembly, then the supplemental inpatient outlier payment for each children's hospital shall be the amount calculated as follows: JUN 2 4 2D1D TN No. 09-03a Approval Date: SUPERSEDES TN No. 07 -909 Effective Date: 11-30 -2009

Attachment 4.19 - A DRAFT - NOT FOR FILING 1) For each eligible children's hospital, the director shall calculate the ratio equal to the amount described m paragraph (E)(1) of this rule divided by the sum of the amount described in paragraph (E)(1) of this rule for all children's hospitals. For children's hospitals that did not have an outlier claim paid in that period, this figure shall be zero. 2) The supplemental inpatient outlier payment for each children's hospital shall be the product of the ratio described in paragraph (F)( 1) of this rule multiplied by the available amount for each fiscal year as provided in Section 309.30. 13 - 309.30. 15 of Amended Substitute House Bill 4491 of the 44th 128th General Assembly. G) If the total funds that would be paid to all children's hospitals under paragraph (E) or F) of this rule exceeds the aggregate inpatient upper limit payment gap for all private hospitals as described in paragraphs (C) and (D) of this rule, then the amount paid to each children's hospital will be the product of the ratio of the amount described in paragraph (F)( 1) of this rule multiplied titesky the aggregate inpatient upper limit payment gap for all private hospitals as described in paragraphs (C) and D) ofthis rule. H) The director shall make supplemental inpatient hospital upper limit payments to children's hospitals if the difference between the total amount the director has paid according to the methodology in paragraph (E) of this rule for cost outlier claims and the total amount the director would have paid according to the methodology in paragraph (A)( 6) or (C)(5) of rule 5101:3 - 2 - 07.9 of the Administrative Code for such claims, as the applicable paragraph existed on June 30, 2007, does not require the expenditure of the available amount for each fiscal year as provided in Section - 309.30. 13 309.30, 15 of Amended Substitute House Bill 44.91 of the 127 t3 128th - General Assembly. If the supplemental outlier payments specified in paragraph (E) of this rule do not require the expenditure of the available amount for each fiscal year as provided in Section 309.30. 13 309.30. 15 of Amended Substitute House Bill -1-149 1 of the 4-27h 128th General Assembly, and are less than the aggregate inpatient upper limit payment gap for all private hospitals as calculated for each supplemental payment program year as described in paragraphs (C) and (D) of this rule then supplemental inpatient hospital upper limit payments to children's hospitals shall be made as follows: 1) In July of each year after the effective date of the medicaid state plan amendment implementing this payment program, the department will calculate for each eligible children's hospital a supplemental inpatient hospital payment amount by multiplying the ratio of each children's hospitals' total medicaid fee- for - service days derived from actual medicaid inpatient discharges paid for through the department's medicaid management information system (MMIS) in the state fiscal year prior to the month of payment, to the total medicaid fee- for - service days from all children's hospitals derived from actual inpatient discharges paid JUN 2 4 2010 TN No. 09 -032 Approval Date: SUPERSEDES TN No..07 -009 Effective Date:11 - 30 -2009

Attachment 4.19 - A DRAFT - NOT FOR FILING for through the department's MMIS in the state fiscal year prior to the month of payment, by the difference between the available amount for each fiscal year as provided in Section 309.30. 13 309.30. 15 of Amended Substitute House Bill 4-19 1 of the 4-2- 7th 128th General Assembly minus the supplemental payments made pursuant to paragraph (E) of this rule, subject to the limitation described in paragraph (H)(2) of this rule. 2) If the total funds that would be paid to all children's hospitals under paragraph H)(1) exceeds the aggregate upper payment limit gap for all private hospitals as calculated for each supplemental inpatient upper limit payment program year as described in paragraphs (C) and (D) of this rule, then the amount paid to each children's hospital will be limited to its proportion, as determined by the ratios described in paragraph (H)(1) of this rule, of the difference between the aggregate upper payment limit gap minus the supplemental payments made pursuant to paragraph (E) of this rule. I) All medicaid payments including payments made under this rule are subject to the limitations described in rule 5101:3 - 2 -24 of the Administrative Code. J) The total funds that will be paid to each children's hospital will be included in the calculation of disproportionate share limits as described in rule 5101:3 - 2 -07.5 of the Administrative Code. JUN 242010 TN No. 09 -032 Approval Date: SUPERSEDES TN No. 07 -009 Effective Date: U-30 -2009

STATE OF OHIO ATTACHMENT 4.19 -A Page 28 Supplemental Payments to Children's Hospitals for Inpatient Outliers A. Notwithstanding paragraph (C)(5) of rule 5101:3 - 2 -07.9 ofthe Ohio Administrative Code, children's hospitals that meet the criteria in paragraphs (E)(1) and (E)(2) ofrule 5101:3 - 2 -07.9 ofthe Administrative Code, will be paid for each cost outlier claim made in fiscal years 2010 and 2011, an amount that is the product of the hospital's allowable charges and the hospital's Medicaid inpatient cost -to- charge ratio. The cost -to- charge ratio is based on the Medicaid charges as reported on the hospital's Medicaid cost report JFS 02930) and the costs attributable to Medicaid as calculated based on the proportion of Medicaid charges to total charges on the hospital's interim settled cost report as applied to the claim year. B. A Children's hospital shall cease being paid for a cost outlier claim under the methodology described in paragraph (A) on page 28 ofAttachment 4.1 9 -A and revert to being paid for such a claim according to methodology in paragraph (A)(6) or (C)(5) of rule 5101 :3 -2 -07.9 of the Administrative Code, as applicable, when the difference between the total amount paid according to the methodology described in paragraph (A) on page 28 ofAttachment 4.19 -A for such claims and the total amount the Director would have paid according to the methodology in paragraph (A)(6) or (C)(5) of rule 5101:3 - 2 - 07.9 of the Administrative Code, as the applicable para ih existed on June 30, 2007, for such claims, exceeds the amount available as descri . in paragraph (D) on page 28 of Attachment 4.19 -A for the applicable fiscal year. C. Payments shall be made under paragraph (D) on page 29 of Attachment 4.19 -A, Supplemental Inpatient Hospital Upper Limit Payments For Children's Hospitals, ifthe difference between the total amount the Director has paid according to the methodology in paragraph (A) on page 28 ofAttachment 4.19 -A for cost outlier claims and the total amount the Director would have paid according to the methodology in paragraph (A)(6) or (CX5) of rule 5101:3 - 2 -07.9 ofthe Administrative Code for such claims, as the applicable paragraph existed on June 30, 2007, does not require the expenditure of the total amount available as described in paragraph (D) on page 28 ofAttachment 4.19 -A for the applicable fiscal year. D. Up to $38.7 million in SFY 2010 and $31.6 million in FFY 2011, shall be used to pay the amounts described in paragraph (A) on page 28 of Attachment 4.19 -A. E. The source data for calculations described in paragraphs (A) on page 28 ofAttachment 4.19 -A through (C) on page 28 ofAttachment 4.19 -A will be based on claims paid for outliers during the prior state fiscal year. F. Payments will be made to children's hospitals on an annual basis, based upon children's hospitals' actual inpatient Medicaid fee - for - service outliers derived from actual Medicaid discharges paid during the prior state fiscal year and upon the difference between what each hospital would be paid according to the methodology described in paragraph (A) on page 28 ofAttachment 4.19 -A the amount the hospital had been paid. G. Hospital payments made under this section shall not exceed the amount available as describ©d in paragraph (D) on page 28 of Attachment 4.19 -A for the applicable fiscal year nor, when combined with other payments made to private hospitals under the State plan, the limit specified in 42 CFR 447.272. Ifthe total funds that would be paid to all children's hospitals exceeds either ofthose amounts, then the amount paid to each children's hospital would be its proportion ofthe lesser of the amount described by paragraphs (A) through (C) on page 29 of Attachment 4.19 -A; or the amount described in paragraph (D) on page 28 of Attachment 4.19 -A. Each hospital's proportion would be equal to the difference between the total amount the Director would pay according to the TN No. 09032. Approval Date: JUN 2 4 20 i 0 Supersedes TN No. 07-009 Effective Date: 11 -30 -09

STATE OF OHIO ATTACHMENT 4.19 -A Page 29 methodology described in paragraph (A) for such claims minus the total amount the Director paid for such claims for that hospital divided by the sum ofthat amount for all children's hospitals. H. Hospital payments made under this section, when combined with other payments made under the State plan shall not exceed the limit specified in 42 CFR 447.271. The total funds that will be paid to each children's hospital will be included in the calculation ofdisproportionate share limits as described in rule 5101:3 - 2 - 07.5 of the Ohio Administrative Code. Supplemental Inpatient Hospital Upper LItnit Payments For Children's Hospitals A. For each Ohio hospital owned or operated by an entity other than a governmental entity, calculate the estimated amount that Medicare would have paid for an inpatient discharge if Medicare were paying the care for Medicaid consumers. a. Inpatient upper payment limit gap calculation for private hospitals excluding private free standing psychiatric hospitals. 1. Divide the total Medicare inpatient hospital payment by the hospital's Medicare inpatient hospital charges to calculate the hospital specific Medicare payment to charge ratio. 2. Multiply the hospital specific Medicare payment to charge ratio by Medicaid charges to calculate the estimated Medicare payment for Medicaid consumers. 3. For each private hospital, calculate the available payment gap by taking total estimated Medicare payment for Medicaid discharges as calculated in paragraph A)(2) and subtracting actual Medicaid payments. b. Inpatient upper payment limit gap calculation for private free standing psychiatric hospitals. 1. Identify inpatient Medicaid costs for each private free standing psychiatric hospitals. 2. Identify inpatient Medicaid payments for each private free standing psychiatric hospitals 3. For each free standing private psychiatric hospital, calculate the inpatient upper payment limit gap by subtracting the amount in paragraph (A)( b)( 2) from the amount in (A)( b)( 1). c. For all private hospitals, the sum of the amounts calculated in paragraph (A)( ax3) and A)( b)( 3) on page 29 ofAttachment 4.19 -A. is the aggregate inpatient upper limit payment gap for all private hospitals. B. The resulting amount calculated in paragraph (A) on page 29 ofAttachment 4.19 -A will be in effect from the effective date ofthe state plan amendment through December 31 of that year, and from January 1 through December 31 ofeach year after. C. The source data for calculations described in this amendment will be based on cost reporting data described in rule 5101:3 - 2 -23 of the Ohio Administrative Code which TN No. 09-032 Approval Date: J U N 201 Supersedes TN No. 07 -009 Effective Date: 11 -30 -09

STATE OF OHIO ATTACHMENT 4. I9 -A Page 30 reflects the most recent completed interim settled Medicaid cost report (JFS 02930) for all hospitals, and the Medicare cost report (CMS 2552 -96) for the corresponding cost reporting period. D. If the Supplemental Payments to Children's Hospitals for Inpatient Outliers do not require the expenditure ofthe amount described under paragraph (D) on page 28 of Attachment 4.19 -A for the supplemental outlier payments and available under the upper payment limit as described by paragraphs (A) on page 29 of Attachment 4.19 -A through C) on page 29 of Attachment 4.19 -A, the department would make additional supplemental payments to children's hospitals up to the lesser of the amount described in paragraph (D) on page 28 ofAttachment 4.19 -A or the amount described by paragraphs A) on page 29 ofAttachment 4.19 -A through (C) on page 29 of Attachment 4.19 -A as follows: Payments will be made to children's hospitals on a annual basis, based upon children's hospitals actual inpatient Medicaid fee- for - service days derived from actual Medicaid discharges paid during the prior twelve -month period, subject to the provisions in paragraph (B) on page 29 ofAttachment 4.19- A. lithe total funds that would be paid to all children's hospitals exceeds the aggregate upper payment limit for all private hospitals, then the amount paid to all children's hospitals will be limited to their proportion of the aggregate upper payment limit. E. Hospital payments made under this section, when combined with other payments made under the State plan shall not exceed the limit specified in 42 CFR 447.271. F. The total funds that will be paid to each children's hospital will be included in the calculation of disproportionate share limits as described in rule 5101:3 - 2 - 07.5 ofthe Ohio Administrative Code. TN No. Q94132 Approval Date: JUN 2 4 2010 Supersedes TN No. 07 -009 Effective Date: 1 1 -30 -09

Attachment 4.19 - A DRAFT - NOT FOR FILING * * 5101:3 - 2 - 53 Supplemental inpatient hospital payments for children's hospitals. This rule sets forth the methodology used to determine the supplemental inpatient hospital payments to children's hospitals required by Section 309.30. 13 309.30. 15 of Amended Substitute House Bill 444 1 of the 128th General Assembly. A) Definitions. 1) " Childress hospital ", for the purpose of this rule, means an Ohio hospital as defined in section 3702.51 of the Revised Code that is owned and operated by a private entity and is subject to prospective payment as described in rule 5101:3- 2 -07.1 of the Administrative Code. 2) " Private hospital" means an Ohio hospital other than as defined in rules 5101:3 - 2- 50 and 5101:3 - 2 - 51 of the Administrative Code. 3) " Available inpatient payment gap" means the difference between what is estimated using the methodology described in paragraphs (C) and (D) of this rule that medicare would have paid for medicaid consumers and actual medicaid payments made in accordance with Chapter 5101:3 - 2 of the Administrative Code. 4) " Total medicaid inpatient payments" for each hospital means the amount paid by the medicaid program for services rendered to eligible medicaid patients, excluding supplemental payments, as reported on the medicaid cost report, as specified in paragraph (B) of this rule. 5) " Total medicaid inpatient discharges" means for each hospital the number of discharges from the facility for medicaid patients, as reported on the medicaid cost report, as specified in paragraph (B) of this rule. 6) " Total medicaid inpatient charges" means for each hospital the charges for covered medicaid inpatient services rendered, as reported on the medicaid cost report, as specified in paragraph (B) of this rule. 7) " Medicare inpatient payments for hospitals exempt from medicare disgnestie - diagnosis related groupsgroup (DRG) payments and medicare inpatient payments for subproviders" means the inpatient payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. 8) " Medicare inpatient DRG payments" means the DRG payment amount as reported on the medicare cost report, as specified in paragraph (B) ofthis rule. 9) " Medicare inpatient outlier payments" means the outlier payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. JUN 2 4 2010 TN No. a.= Approval Date: SUPERSEDES TN No. D7 -009 Effective Date: 11 -30 -2009

Attachment 4.19 - A DRAFT - NOT FOR FILING 10) " Medicare inpatient indirect medical education" means the indirect medical education adjustment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. 11) " Medicare inpatient disproportionate share payments" means the inpatient disproportionate share adjustment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. 12) " Medicare inpatient hospital capital payments" means" the payment for inpatient program capital as reported on the medicare cost report, as specified in paragraph (B) of this rule. 13) " Medicare inpatient direct medical education" means the direct graduate medical education payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule. 14) " Medicare inpatient hospital payments - other" means the sum of net organ acquisition cost, cost of teaching physicians, routine service other pass through costs, and ancillary service other pass through costs, as reported on the medicare cost report, as specified in paragraph (B) of this rule. 15) " Total medicare inpatient charges" means the amount of inpatient charges for each hospital and subprovider, as reported on the medicare cost report, as specified in paragraph (B) of this rule. 16) " Total medicaid days" means for each children's hospital the number of days reported from the facility for medicaid fee - for - service patients, as reported on the medicaid cost report, as specified in paragraph (B) of this rule. 17) " Program year" means the twelve -month period beginning on the first day of January and ending on the thirty -first day of December. 18) " Medicaid inpatient cost -to- charge ratio" means the historic medicaid inpatient cost -to- charge ratio applicable to a hospital as described in paragraph (B)( 2) of rule 5101:3 - 2 - 22 of the Administrative Code. B) Source data for calculations. Unless otherwise specified, the calculations described in this rule will be based on cost reporting data described in rule 5101:3 - 2 -23 of the Administrative Code that reflects the most recent completed interim settled medicaid cost report for all hospitals, and the medicare cost report for the corresponding cost reporting period. C) Calculation of available inpatient payment gap for private hospitals. JUN 2 4 2010 TN No. 09-032 Approval Date: SUPERSEDES TN No. 07 -009 Effective Date: 11 -30 -2009

Attachment 4.19 - A DRAFT - NOT FOR FILING * * 1) Calculation of available inpatient payment gap for private hospitals that are not free- standing psychiatric hospitals. a) For each private hospital, calculate the total medicare inpatient payment by adding the amounts described inparagraphs (A)( 7) to (A)( 14) of this rule. b) For each private hospital. calculate the medicare payment -to- charge ratio by dividing the atnoupt calculated in paragraph (C)( 1)( a) of this rule by the total medicare inpatient charges as described in paragraph (A)( 15) of this rule. c) For each private hospital, calculate the _total estiwat. d medicare inpatient payment for medicaid inpatient discharges by multiplying the amount calculated in paragraph (C)(1 Kb) of this rule by the total medicaid inpatient charges as desc . bed in paragraph (A)( 6) of this ntle. d) For each private hospital. calculate the available inpatient payment gap by taking total estimated medicare inpatient payments for medicaid inpatient discharges as calculated in paragraph (C)( 1)( c) of this rule and subtracting actual total medicaid inpatient payments as described in paragraph (A)( 4) of this rule. e) For each private hospital that has Ali available inpatient payment gap greater than zero resulting from the calculations in paragraph (C)( 1)( d) of this rule, calculate the available per discharge supplemental inpatient hospital payment amount by dividing the amount in paragraph (C)( 11( d) of this rule by the amount in paragraph (A)( 5) of this rule. 2) Calculation of available inpatient payment gap for private psychiatric hospitals PPH) subject to medicaid prospective payment as described in rule 5101:3 - 2- 07.8 of the Administrative Code and excluded from prospective payment under medicare, 42 C.F. R. 412.23( a) in effect as of October 1. 2003. a) For each PPH described in this paragraph, "medicaid inpatient costs" means medicaid inpatient costs as reported on the medicaid cost report, as specified in paragraph (B) of this rule. b) For each PPH described in this paragraph. "medicaid inpatient payments" means medicaid inpatient payments as reported on the medicaid cost report, as specified in paragraph (B) of this rule. 1c) For each PPH described in this paragraph. "medicaid discharges" means medicaid discharges as reported on the medicaid cost report, as specified in paragraph (B) of this rule. JUN 2 4 2010 TN No. 0 Approval Date: SUPERSEDES TN No. 47 -009 Effective Date: 11 - - 2009

Attachment 4.19 - A DRAFT - NOT FOR FILING * d) For each PPH described in this paragraph. calculate the available inpatient payment gap by subtracting the amount in .paragraph (C)( 2)( b) of this rule from the amount in paragraph (C)( 2)( a) of this rule. e) For each PPH described in this paragraph that has an available inpatient payment gap greater than zero resulting from the calculations in paraaraph(C)( 2)( d) of this rule. calculate the available per discharge supplemental inpatient hospital payment amount by dividing the amount in paragraph (C)( 2)( d) of this rule by the amount in paragraph (C)( 2)( c) of this rule. 3) For all private hospitals. sum the amounts calculated in paragraphs (C)( 11( d) and C)( 2)( d) of this rule. This is the aggregate inpatient upper limit for all private hospitals. hospitals D) For each supplemental payment made after the effective date of this rule, the resulting upper payment limit calculated in paragraph (C) of this rule will be in effect from the first day of January through the thirty -first day of December for each supplemental payment program year. E) Notwithstanding paragraph (C)( 5) of rule 5101:3 - 2 - 07.9 of the Administrative Code and except as provided in paragraph (F) of this rule, the director of the Ohio TN No. 09-032 Approval Date: UN 2 4 2010 SUPERSEDES TN No. 97 -009 Effective Date: 11 -30 - 2009

Attachment 4.19 - A DRAFT - NOT FOR FILING department of job and family services (ODJFS) shall pay a children's hospital that meets the criteria . in paragraphs (Ex 1) and (EX2) of rule 5101:3 - 2 - 07.9 of the Administrative Code, for each cost outlier claim made in fiscal years 2085- and-2009 2010 and 2011, an amount that is the product of the hospital's allowable charges and the hospital's medicaid inpatient cost -to- charge ratio. These payments shall be made as supplemental inpatient outlier payments as follows: 1) In July of each year after the effective date of the medicaid state plan amendment implementing this payment program, the director shall calculate for each eligible children's hospital the difference between the total amount the director would have paid according to the methodology in paragraph (E) of this rule for such claims for services incurred during the prior state fiscal year using the same cost -to- charge ratio as the ratio used to calculate cost outlier payments in accordance with rule 5101:3- 2- 07. 9 of the Administrative Code for services incurred during that tune period and the total amount the director paid according to the methodology in paragraph (A)( 6) or (C)(5) of rule 5101:3 - 2 -07.9 of the Administrative Code, as the applicable paragraph existed on June 30, 2007, for such claims as reflected in actual medicaid inpatient claims paid through the department's medicaid management information system (MMIS) in the prior state fiscal year. 2) If the sum of the amounts calculated in paragraph (E)( 1) of this rule for all eligible children's hospitals is less than or equal to the available amount for each fiscal year as provided in Section 309.30. 13 309.30. 15 of Amended Substitute House Bill 449 1 of the 4-2 I 28th General Assembly, then the supplemental inpatient outlier payment for each children's hospital shall be the amount calculated in paragraph (E)( 1) of this rule. Otherwise, the supplemental inpatient outlier payment for each children's hospital shall be the amount calculated in paragraph (F) of this rule. F) The director shall cease paying a children's hospital for a cost outlier claim under the methodology in paragraph (E) of this rule and revert to paying the hospital for such a claim according to methodology in paragraph (A)( 6) or (C)(5) of rule 5101:3 - 2 - 07.9 of the Administrative Code, as applicable, when the difference between the total amount the director would pay according to the methodology in paragraph (E) ofthis rule for such claims and the total amount the director paid according to the methodology in paragraph (AX6) or (C)(5) of rule 5101:3 - 2 - 07.9 of the Administrative Code, as the applicable paragraph existed on June 30, 2007, for such claims, exceeds the available amount for each fiscal year as provided in Section - 309.30. 13309.30. 15 of Amended Substitute House Bill 4-1- 91 of the 4- 128th - General Assembly. If the sum of the amounts calculated in paragraph (EXI) of this rule for all eligible children's hospitals is greater than the available amount for each fiscal year as provided in Section 309.30. 13309.30. 15 of Amended Substitute House Bill 4491 of the 4- 27th 128th General Assembly, then the supplemental inpatient outlier payment for each children's hospital shall be the amount calculated as follows: JUN 2 4 2010 TN No. 09-032 Approval Date: SUPERSEDES TN No. 07 -009 Effective Date: 11 -30 -2009

Attachment 4.19 - A DRAFT - NOT FOR FILING 1) For each eligible children's hospital, the director shall calculate the ratio equal to the amount described in paragraph (E)( 1) of this rule divided by the sum of the amount described in paragraph (E)( 1) of this rule for all children's hospitals. For children's hospitals that did not have an outlier claim paid in that period, this figure shall be zero. 2) The supplemental inpatient outlier payment for each children's hospital shall be the product of the ratio described in paragraph (F)( 1) of this rule multiplied by the available amount for each fiscal year as provided in Section 309.30. 13 - 309.30. 15 of Amended Substitute House Bill 4- 191 of the 127th 128th General Assembly. G) If the total funds that would be paid to all children's hospitals under paragraph (E) or F) of this rule exceeds the aggregate inpatient upper limit payment gap for all private hospitals as described in paragraphs (C) and (D) of this rule, then the amount paid to each children's hospital will be the product of the ratio of the amount described in paragraph (F)( 1) of this rule multiplied timesh,,,y the aggregate inpatient upper limit payment gap for all private hospitals as described in paragraphs (C) and D) ofthis rule. H) The director shall make supplemental inpatient hospital upper limit payments to children's hospitals if the difference between the total amount the director has paid according to the methodology in paragraph (E) of this rule for cost outlier claims and the total amount the director would have paid according to the methodology in paragraph (A)( 6) or (C)( 5) of rule 5101:3 - 2 - 07.9 of the Administrative Code for such claims, as the applicable paragraph existed on June 30, 2007, does not require the expenditure of the available amount for each fiscal year as provided in Section - 309.30. 13 309,30. 15 of Amended Substitute House Bill 4-1- 91 of the 28th - General Assembly. If the supplemental outlier payments specified in paragraph (E) of this rule do not require the expenditure of the available amount for each fiscal year as provided in Section 309.30. 13 309.30. 15 of Amended Substitute House Bill 149 1 of the 128th General Assembly, and are less than the aggregate inpatient upper limit payment gap for all private hospitals as calculated for each supplemental payment program year as described in paragraphs (C) and (D) of this rule then supplemental inpatient hospital upper limit payments to children's hospitals shall be made as follows: 1) In July of each year after the effective date of the medicaid state plan amendment implementing this payment program, the department will calculate for each eligible children's hospital a supplemental inpatient hospital payment amount by multiplying the ratio of each children's hospitals' total medicaid fee - for - service days derived from actual medicaid inpatient discharges paid for through the department's medicaid management information system (MMIS) in the state fiscal year prior to the month of payment, to the total medicaid fee - for - service days from all children's hospitals derived from actual inpatient discharges paid JUN 2 4 2010 TN No. 09 -032 Approval Date: SUPERSEDES TN No. 07 -009 Effective Date: .11-30- 2009

Attachment 4.19 - A DRAFT - NOT FOR FILING for through the department's MMIS in the state fiscal year prior to the month of payment, by the difference between the available amount for each fiscal year as provided in Section 309.30. 13 309.30. 15 of Amended Substitute House Bill 444 1 of the -12-7th 128th General Assembly minus the supplemental payments made pursuant to paragraph (E) of this rule, subject to the limitation described in paragraph (H)(2) of this rule. 2) If the total funds that would be paid to all children's hospitals under paragraph H)(1) exceeds the aggregate upper payment limit gap for all private hospitals as calculated for each supplemental inpatient upper limit payment program year as described in paragraphs (C) and (D) of this rule, then the amount paid to each children's hospital will be limited to its proportion, as determined by the ratios described in paragraph (H)(1) of this rule, of the difference between the aggregate upper payment limit gap minus the supplemental payments made pursuant to paragraph (E) of this rule. I) All medicaid payments including payments made under this rule are subject to the limitations described in rule 5101:3 - 2 -24 of the Administrative Code. J) The total funds that will be paid to each children's hospital will be included in the calculation of disproportionate share limits as described in rule 5101:3 - 2 -07.5 of the Administrative Code. JUN 242010 TN No. 09 Approval Date: SUPERSEDES TN No. Q.Z.. 009 Effective Date: 11

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 1. TRANSMITTAL NUMBER: 0 9-032 2. STATE OHIO FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3· PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): 4. PROPOSED EFFECITVE DA TE NOVEMBER 30, 2009 0 NEW ST ATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PL~\f ~ AMENDMENT COMPLETE BLOCKS 6 THRU I 0 IF THIS IS AN AMENDMENT (Se arate Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: 42CFR440;42CFR 441;42CFR 447 a.FFY 2010 $11.9million b. FFY 201 l $ 8.6 million 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT 4.19-A pages 28, 29 and 30 Ohio Administrative Code Rule 5101:3-2-53 10. SUBJECT OF AMENDMENT: Supplememal inpatient hospital payment'i for children's hospitals. 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED \\-1THIN 4.5 DAYS OF SUBMITTAL OR A TI ACHMENT (If Applicable): ATTACHMENT 4.19-A, pages 28, 29 and30 Ohio Administrative Code Ruic 5101:3-2-53 i2?J OTHER, AS SPECIFIED: Governor bas deleg•ted signature authority to ODJFS Director. Director bas delegated signature authority to Medicaid Director 16. RETURN TO: --..,.,-,--...J.,=-~!-l+..=_,1.A.~~~~;::;~,,,..,...,:-::--::-------l Becky Jackson I OHP/Bureau of Policy and Benefit Management -14-. T-ITL--E-: ---S-T-ATE--M-E_D_l_C_AID __ D_IRE_CT_O_R ____ ---<! ~~~~of Job and Family Services -1-5-. D_A_TE_S_UB_M_I_lTE_D_: ---------------1 Columbus, Ohio 43218 Instructions on Back FORM CMS-179 (07-92)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop $3-13-15

Baltimore, Maryland 21244-1850 CENTERS for MEDICARE & MEDICAID SERVICES Fj

Center for Medicaid and CHIP Services (CMCS)

John McCarthy, Medicaid Director

Office of Ohio Health Plans

Ohio Department of Job and Family Services (ODJFS) JAN 26 20 P.O. Box 182709

50 West Town Street, Suite 400

Columbus, Ohio 43218

RE: Ohio State Plan Amendment (SPA) 10-001 Dear Mr. McCarthy:

We have reviewed the proposed amendment to Attachments 4.19-D of your Medicaid State plan submitted under transmittal number (TN) 10-001. Effective for services on or after July 1, 2010, this amendment revises methods and standards for reimbursement rates for NF and ICF/MR services. Specifically, this amendment provides an additional amount for real estate taxes for those facilities that had a credit reducing their real estate taxes reflected on the base year cost report to zero. Additionally, this amendment decreases the per diem rate for the State’s outlier ICF/MR.

We conducted our review of your submittal according to the statutory requirements at sections 1902(a)(2), 1902(a)(13), 1902(a)(30), and 1903(a) of the Social Security Act and the regulations

at 42 CFR 447 Subpart C. We hereby inform you that Medicaid State plan amendment 10-001 is approved effective July 1, 2010. We are enclosing the HCFA-179 and the amended plan pages.

If you have any questions, please call odd McMillion at (608) 441-5344. Sincerely,

Cindy Mann, Director (CMCS)

Enclosure

309.30.25.000

Attachment 4.19D NF Supplement 1 Page 1 of 3

SECTION 309.30.25. FISCAL. YEAR 2011 MEDICAID REIMBURSEMENT SYSTEM FOR

NURSING FACILITIES

(A) Except as provided in division (A)(1)(A) of this section, the provider of a nursing facility that has a valid Medicaid provider agreement shall be paid the rate determined as follows:

(i) For nursing facility services the nursing facility provides during fiscal year 2011, determine the rate for the nursing facility under sections 5111.20 to 5111.33 of the Revised Code with the following adjustments:

(a)

(b)

The cost per case mix-unit calculated under section 5111.231 of the Revised Code, the rate for ancillary and support costs calculated under section 5111.24 of the Revised Code, the rate for tax costs calculated under section 5111.242 of the Revised Code, and the rate for capital costs calculated under section 5111.25 of the Revised Code shall each be adjusted as follows:

(i)

(ii)

(iii)

(iv)

Increase the rate determined under division (A)(1)(a) of this section by two per cent;

Increase the rate determined under division (A)(1)(a)@) of this section by two per cent;

Increase the rate determined under division (A)(1)(a)(ii) of this section by one per cent;

Increase the rate determined under division (A)(1)(a)Gii) of this section by the quality incentive payment calculated under section 5111.244 of the Revised Code. The quality incentive payment shall be established for each provider so that the mean payment is equal to three dollars and three cents.

Except as provided in division (A)(1)(e) of this section, if the rate determined for a nursing facility under division (A) of this section for nursing facility services provided during fiscal year 2011 is more than one hundred two and twenty-five hundredths per cent of the nursing

TN # 10-001 Approval Date: JAN 26 2012 Supersedes TN #.09-013 Effective Date: 07/01/10

309.30.25.000

©)

@)

()

Attachment 4.19D NF Supplement 1 Page 2 of 3

facility's rate on June 30, 2010, the Department of Job and Family Services shall reduce the nursing facility's rate determined under division (A) of this section for fiscal year 2011 so that the rate is not more than one hundred two and twenty-five hundredths per cent of the nursing facility's rate on June 30, 2010. Except as provided in division (A)(1)(e) of this section, if the rate determined for a nursing facility under division (A) of this section for nursing facility services provided during fiscal year 2011 is less than ninety-nine per cent of the nursing facility's rate on June 30, 2010, the Department shall increase the nursing facility's rate determined under division (A) of this section for fiscal year 2011 so that the rate is not less than ninety-nine per cent of the nursing facility's rate on June 30, 2010.

After the adjustments under division (A) of this section are made to a nursing facility's fiscal year 2011 rate, the Department of Job and Family Services shall increase the nursing facility's fiscal year 2011 rate by five dollars and seventy cents per Medicaid day: This increase shall be known as the workforce development incentive payment. The total amount of workforce development incentive payments paid to providers of nursing facilities shall be used to improve nursing facilities' employee retention <id direct care staffing levels, including by increasing wages paid to nursing facilities' direct care staff. Not later than September 30, 2012, the Department shall submit a report to the Governor and; in accordance with section 101.68 of the Revised Code, the General Assembly detailing the impact:that the workforce development incentive payments have on nursing facilities' employee retention, direct care staffing levels, and direct care staff wages.

After the adjustment under division (A)(1)(c) of this section is made to a nursing facility's fiscal year 201 1 rate, the Department of Job and Family Services shall increase the nursing facility's fiscal year 2011 rate by the consolidated services rate per Medicaid day. The consolidated services rate shall be three dollars and ninety-one cents.

After the adjustments under division (A) of this section are made to a nursing facility's fiscal year 2011 rate, the Department of Job and Family Services shall increase the nursing facility's fiscal year 2011 rate by the

TN# 10-001 Approval Date: JAN 26 ante

Supersedes TN #09-013 Effective Date: 07/01/10

309.30.25.000

®)

(2)

03)

Attachment 4.19D NF Supplement 1 Page 3 of 3

amount of real estate taxes reported on the nursing facility's cost report for calendar year 2004 divided by the number of inpatient days reported on that cost report if the nursing facility had a credit reducing its real estate taxes reflected on its cost report for calendar year 2003 to zero. When the rate is paid for Medicaid days, the payment is only for the Medicaid portion of the tax expense.

If the fiscal year 2010 rate for a nursing facility as initially determined under section 309.30.20.000 is not subject to an adjustment under division (A)(1)(b) of that section, the nursing facility's fiscal year 2011

rate as initially determined under division (A) of this section shall not be subject to an adjustment under division (A)(1)(b) of this section regardless of whether the nursing facility's fiscal year 2011 rate as initially determined under division (A) of this section would, if not for this division, be subject to the adjustment. Ifthe fiscal year 2011 rate for a nursing facility as initially determined under division (A) of this section is not subject to an adjustment under division (A)(1)(b) of this section, the nursing facility's rate shall not be subject to an adjustment under that division for the remainder of fiscal year 2011 regardless of any other adjustment made to the nursing facility's fiscal year 2011 rate under sections 5111.20 to 5111.33 of the Revised Code.

For services provided after June 30, 2011, nursing facilities shall continue to be paid the nursing facility's rate for June 30, 2011. Ifa participating nursing facility does not have arate paid on June 30, 2011, the nursing facility shall be paid pursuant to Sections 5111.254.000, 5111.254.001, 5111.676.000, and 5111.676.001.

The Department of Job and Family Services shall follow this section in determining the rate to be paid to the provider of a nursing facility that has a valid Medicaid provider agreement on June 30, 2010, and a valid Medicaid provider agreement for fiscal year 2011 notwithstanding anything to the contrary in sections 5111.20 to 5111.33 of the Revised Code.

TN # 10-001 Approval Date: JAN 26 2012

Supersedes TN #.09-013 Effective Date: 07/01/10

5101:3-3-17.5 Attachment 4.19D ICF-MR Supplement 2 Page 1 of 1

"SUNSHINE/KING ROAD FAMILY CARE HOME is an ICF-MR outlier provider on the Medicaid program. SUNSHINE/KING ROAD FAMILY CARE HOME receives a per diem rate of $442.93 per resident per day for each Medicaid resident in lieu of the calculated rate set forth under ICF-MR Supplement 2."

JAN 26 2012 TN # 10-001 Approval Date:

Supersedes TN #09-014 Effective Date 07/01/10

OS Notification

State/Title/Plan Number: Ohio 10-001

Type of Action: SPA Approval

Required Date for State Notification: February 1, 2012

Fiscal Impact:

FY 2010 $ 345,676 FY 2011 $ 1,004,988

Number of Services Provided by Enhanced Coverage, Benefits or Retained Enrollment: 0

Number of Potential Newly Eligible People: 0

Eligibility Simplification: No

Provider Payment Increase: Yes

Delivery System Innovation: No

Number of People Losing Medicaid Eligibility: No

Reduces Benefits: No

Detail:

Effective July 1, 2010, this amendment provides an additional amount for real estate taxes for those NFs that had a credit reducing their real estate taxes reflected on the base year cost report to zero. Additionally, this amendment decreases the per diem rate for the State’s outlier ICF/MR. The State met public process requirements. Funding the non-Federal share of these payments comes from State appropriations and provider tax. There are no issues with the UPL.

Despite the rate reduction for the State’s one outlier ICF/MR, the State feels Medicaid recipients will still have adequate access to care and services. The rate for the outlier facility is based on actual costs and is negotiated directly with the provider on an annual basis. Any concerns the provider may have are addressed during the annual negotiation. The State’s response is acceptable.

Ohio pays NFs a per diem rate that includes Direct Care Costs, Ancillary & Support Costs, Tax Costs, Franchise Permit Fees, and Capital Costs. Adjustments are applied as well as a rate ceiling and floor that depends on the previous year’s rate. This amendment proposes an increase to the NF rate for FY 2011 equal to the amount of real estate taxes reported on the NF’s cost report for calendar year 2004 divided by the number of inpatient days reported on that cost report if the NF had a credit reducing its real estate taxes reflected on its cost report for calendar year 2003 to zero. 2003 was a rebasing year for the NF rate. Since the NF rate is a per diem rate that is applied to Medicaid days, this add-on should only be for Medicaid’s portion of the tax.

The State plan also provides for a per diem rate to be paid to the State’s lone outlier ICF/MR, Sunshine/King Road Family Care Home. This amendment proposes to decrease that per diem rate from the current amount of $470.03 to $442.93 per resident per day for each Medicaid resident.

Other Considerations:

This plan amendment has not generated significant outside interest and we do not recommend the Secretary contact the governor.

Recovery Act Impact:

The Regional office has reviewed this state plan amendment in conjunction with the Recovery Act and, based on the available information provided by the State regarding 1) MOE; 2) local match; 3) prompt pay; 4) rainy day funds, and 5) eligible expenditures, the Regional Office believes that the State is not in violation of the Recovery Act requirements noted above.

CMS Contact:

Todd McMillion (608) 441-5344 National Institutional Reimbursement Team

TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL

FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES

1. TRANSMITTAL NUMBER: 2. STATE 10 - 001 OHIO

3, PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)

TO: REGIONAL ADMINISTRATOR. CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES

4, PROPOSED EFFECTIVE DATE July 1, 2010

5. TYPE OF PLAN MATERIAL (Check One):

[1] NEW STATE PLAN

(] AMENDMENT TO BE CONSIDERED AS NEW PLAN

AMENDMENT

COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)

6. FEDERAL STATUTE/REGULATION CITATION:

7, FEDERAL BUDGET IMPACT: a. FFY 2010 $ 345,676 b. FFY 2011 $1,004,988

8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:

Section 309.30.25, NF Attachment 4.19D Section 5101:3-3-17.5, ICF-MR Attachment 4.19D Tb Ce ee ee toneaaa cies

9, PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):

Section 309.30.25, NF Attachment 4.19D Section 5101:3-3-17.5, ICF-MR Attachment 4.19D

Table of Content Medial Sse lan. Mating Fes

10. SUBJECT OF AMENDMENT: State plan amendment TN 10-001 modifies rate growth for nursing facilities. It also includes a new provision that provides an additional amount for real estate taxes for those facilities that had a credit reducing their real estate taxes reflected on the base year cost report to zero. This amendment also modifies the state fiscal year 2011 Medicaid per diem rate for the state's ICF-MR outlier facility.

11. GOVERNOR’S REVIEW (Check One): [1] GOVERNOR’S OFFICE REPORTED NO COMMENT [_] COMMENTS OF GOVERNOR’S OFFICE ENCLOSED [UNO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL

OTHER, AS SPECIFIED:

Governor has delegated signature authority to ODJFS Director. Director has delegated signature authority to Medicaid Director

12. SI 5 ii STATE hae OFFICIAL: 16 RETURN TO: Foi J. Vi onle [wh 13. TYPED NAME: TRACY J. PLOUCK Becky Jackson

14, TIFLE: STATE MEDICAID. DIRECTOR

15. DATE SUBMITTED: 4.40.18

OHP/B eau of Policy and Benefit Management arbiter of .ob and Family Services

‘Cohimbiis; Ohio 43218°

FOR REGIONAL OFFICE USE ONLY

17. DATE RECEIVED:

18. DATE APPROVED:

JAN 26 2012

PLAN APPROVED — ONE COPY ATTACHED

19. EFFECTIVE DATE OF APPROVED MATERIAL:

JUL - 1 2010 21. TYPED NAME: yy Mat

20. re Duly REGIONAL OFFICIAL: TLEY ”

purty \eeroR | CMCS

nem psont 23. REMARKS:

bh F § an GF

FORM HCFA-179 (07-92)

Department of Health & Human Services CAWS Centers for Medicare & Medicaid Services 233 North Michigan Avenue, Suite 600 CENTERS for MEDICARE &MEDICAID SERVICES Chicago, Illinois 60601 -5519 JUN 2 8 2010 Tracy Plouck, Deputy Director Office of Ohio Health Plans Ohio Department of Job and Family Services P.O. Box 182709 50 West Town Street, Suite 400 Columbus, Ohio 43218 RE: TN 10 -005 Dear Ms. Plouck: Enclosed for your records is an approved copy of the following State Plan Amendment: Transmittal #10 - 005 An amendment to implement continuous eligibility for children under Section 1902(e)( 12) and presumptive eligibility for children under Section 1920A of the Social Security Act. Please contact Heather Brown - Palsgrove, of my staff, at 312) 886 -2417 or heather .brown- palsgrove@,cros. hhs.gov if you have any questions. Sincere y, r on Johns' Associate R . nal Administrator Division of Medicaid and Children's Health Operations Enclosure cc: Becky Jackson, Ohio State Plan Coordinator Daphne Kackloudis, Section Chief, Bureau of Policy and Benefit Management Debbie Saxe, Chief, Bureau of Policy and Health Plan Services Kathy Hoeffer, Chief, Bureau of Consumer and Operational Support

ATTACHMENT 2.2 -A PAGE 23c STATE OF OHIO STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Citation Groups Covered 1902(a)( 10)( A)( ii)( XIV) X Optional Targeted Low Income Children (con't.) of the Act The state covers: All children described above who are under age 19 with family income at or below 200 percent of the federal poverty level. The following reasonable classification of children described above who are under age _ (18,19) with family income at or below the percent of the federal poverty level specified for this classification: 1902(e)( 12) of the Act X 20. Continuous Eligibility for Children A child under age 19 (not to exceed age 19) who has been determined eligible under 1902(a)( 10)( A) of the Act is deemed to be eligible for a total of 12 months (not to exceed 12 months) regardless of changes in circumstances, other than moving out of state or attainment of maximum age stated above, until the earlier of: a. The end of a period (not to exceed 12 months) of continuous eligibility; or b. The time that the individual exceeds that age. TN No. 10 -005 Approval Date JUN 2 8 2010 Effective Date 04/01/ 10 Supersedes TN No. 00 -002

ATTACHMENT 2.2 -A PAGE 23c1 STATE OF OHIO STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT Citation Groups Covered 1920A of the Act X 21. Presumptive Eligibility for Children Children under age 19 (no more than 19) who are determined by a "qualified entity" (as defined in section 1920A(b)( 3)( A)) based on preliminary information, to meet the highest applicable income criteria specified in this plan under ATTACHMENT 2.6 -A and are therefore determined to be presumptively eligible during a presumptive eligibility period in accordance with 1920A of the Act. The presumptive period begins on the day that the determination is made. If an application for Medicaid is filed on the child's behalf by the last day of the month following the month in which the determination of presumptive eligibility was made, the presumptive period ends on the day the state agency makes a determination of eligibility based on that application. If an application is not filed on the child's behalf by the last day of the month following the month the determination of presumptive eligibility was made, the presumptive period ends on that last day. The following types of "qualified entities" are used to determine presumptive eligibility: The county departments of job and family services of the State of Ohio. The State requires that a written application be completed and signed by the child's parents or other representative: a- - No The written application requests the following identifying information: Information collected to determine presumptive eligibility include age, residency, U.S. citizenship or qualified alien status, and gross family income. This information is gathered based on self- attestation. TN No. 10 -005 Approval DateJUN 2 0 2010 Effective Date 04/01/ 10 Supersedes TN No.

TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2. STATE STATE PLAN MATERIAL 10 -005 Ovz4. J OHIO FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE CENTERS FOR MEDICARE & MEDICAID SERVICES April 1, 2010 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Check One): NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittalfor each amendment) 6. FEDERAL STATUTE /REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: CHIPRA § 104: 2105(a)( 4)( A), 1902(e)( 12) a. FFY 2010 5,641 CHIPRA § 104: 2105(a)( 4)( F), 1920A b. FFY 2011 57,211 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicable): Attachment 2.2 -A, page 23c Attachment 2.2 -A, page 23c (TN 00 -002) Attachment 2.2 -A, page 23c1 N/A 10. SUBJECT OF AMENDMENT: This amendment serves to implement Section 1902(a)( 10)(A) of the Social Security Act (the Act), including continuous eligibility under Section 1902(e)( 12) and presumptive eligibility for children under Section 1920A of the Act . Ohio is a Medicaid expansion state under Title XXI; this is a companion state plan submission to our Title XXI state plan amendment, SCHIP #5. 11. GOVERNOR'S REVIEW (Check One): GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Governor has delegated signature authority NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL to ODJFS Director. Director has delegated signature authority to State Medicaid Director l2. SIGNA • ' TATE AG . / CY OFFICIAL: 16. RETURN TO: i Becky Jackson 13. T ED NA f, : TRACY J. PLOUCK OHP/Bureau of Policy and Health Plan Services 14. TITLE: STATE MEDICAID DIRECTOR Ohio Department of Job and Family Services P.O BOX 182709 15. DATE SUBMITTED: 03/30/ 10 Columbus, Ohio 43218 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: 0 - 30 -10 JUN 2 g 2010 PLAN APPROVED — ONE COPY A 1 ACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: kwor F GIONAL OFFICIAL: 04 -01 -1 0 21. TYPED NAME: 22. TITLE: Verlon Johnson 4qsn - itatP RPgio.nal Administrator 23. REMARKS: Instructions on Back FORM CMS -179 (07 -92)

DEPARTMENT OF HEALTH & HUMAN SERVICES CII. Ay Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop $2-26-12

CENTERS for MEDICARE & MEDICAID SERVICES Baltimore, Maryland 21244-1850

Center for Medicaid, CHIP, and Survey & Certification (CMCS)

Tracy Plouck, Deputy Director

Office of Ohio Health Plans

Ohio Department of Job and Family Services Noy 29 2010 P.O. Box 182709

50 West Town Street, Suite 400

Columbus, Ohio 43218

RE: Ohio 10-006 Dear Ms. Plouck:

Attached are pages for State plan amendment submitted under transmittal number (TN) 10-006 to be incorporated into your Medicaid State plan.

If you have any questions, please call Todd McMillion at (608) 441-5344.

Sincerely,

yr Cindy Mann,

Director (CMCS)

Enclosure

>

ACTION: Original DATE: 06/30/2010 P13 PM

$101:3-2-23 Cost reports.

(A) For cost-reporting purposes, the medicaid program requires each eligible provider, as defined in rule 5101:3-2-01 of the Administrative Code, to submit periodic reports that generally cover a consecutive twelve-month period of the provider's operations.

Failure to submit all necessary items and schedules will only delay processing and may result in a reduction of payment or termination as a provider as described in paragraph (H) of this rule.

Effective for medicaid cost reports filed for cost-reporting periods ending in state fiscal year (SFY) 2003, and each cost-reporting period thereafter, any hospital that fails to submit cost reports on or before the dates specified by ODJFS shall be fined one thousand dollars for each day after the due date that the information is not reported.

The hospital shall complete and submit the JFS 02930 "Hospital Cost Report" in accordance with instructions contained in this rule. The JFS 02930 (rev. 4/20092010) for SFY 20692010 and its instructions are shown in the appendix to this rule. The hospital's cost report must:

(1) Be prepared in accordance with medicare principles governing reasonable cost reimbursement set forth in the providers’ reimbursement manual "CMS

Publications 15, 15-1 and 15-2," available at http://www.cms.hhs.gov/Manuals/PBM/list.asp#TopOfPage dated September 8, 2005.

(2) Include all information necessary for the proper determination of costs payable under medicaid, including financial records and statistical data.

(3) Be submitted in accordance with the instructions in the appendix to this rule an electronic copy of the medicare cost report, which must be identical in all respects to the cost report submitted to the medicare fiscal intermediary.

(4) Include the cost report certification executed by an officer of the hospital attesting to the accuracy of the cost report and to the accuracy of the OBRA survey. In addition, all subsequent revisions to the cost report must include an executed certification.

(5) Effective for medicaid cost reports filed for cost-reporting periods ending in SFY 2003, and each cost-reporting period thereafter, the executed

NOV 29 200

{ stylesheet: rule.xsl 2.14, authoring tool: i4i 2.0 Apr 9, 2003, (dv: 5. p: 64177, par 114139, va: 240470, d: 292946) date: 07/0624 04:37 PM TN No. 10-006 Approval Date: SUPERSEDES TN No. 09-027 Effective Date: 07-01-2010

Attachment 4.19 - A

5101:3-2-23 2

certification shall require the officer of the hospital to acknowledge that an independent party, a certified public accountant, has successfully verified the data reported on "Schedule F" of the cost report in accordance with the procedures included in the cost report instructions. In addition, all subsequent revisions to "Schedule F" shall also be successfully verified by an independent, certified public accountant in accordance with the recertification procedures included in the cost report instructions.

(B) Hospitals having a distinct part psychiatric or rehabilitation unit recognized by medicare in accordance with the provisions of 42 C.F.R. 412.25 effective October 1, 2006, 42 C.F.R. 412.27 effective July 1, 2006, and 42 C.F.R. 412.29 effective January 1, 2005, must identify distinct part unit costs separately within the cost report as described in paragraph (A) of this rule.

(C) Ohio hospitals performing transplant services covered under medicaid as described in rule 5101:3-2-07.1 of the Administrative Code must identify transplant costs, charges, days, and discharges separately within the cost report as described in paragraph (A) of this rule.

(D) Ohio hospitals performing ambulatory surgery within the hospital outpatient setting must identify ambulatory surgery costs and charges separately within the cost report as described in paragraph (A) of this rule.

(E) Ohio hospitals providing services to medicaid managed care plan (MCP) enrollees must identify MCP costs, charges and payments separately within the cost report as described in paragraph (A) of this rule.

(F) It is not necessary for the hospital to wait for the medicare (Title XVIII) audit in order to file the initial cost report for the stated time period. The interim cost report filing can be audited by the ODJFS prior to any applicable final adjustment and settlement. If an amount is due ODJFS as a result of the filing, payment must be forwarded, in accordance with the instructions in the appendix to this rule, at the time the cost report is submitted for it to be considered a complete filing. Any revised interim cost report must be received within thirty days of the provider's receipt of the interim cost settlement. A desk audit will be performed by the hospital audit section on all as filed and interim cost reports. An interim cost settlement by ODJFS does not preclude the finding of additional cost exceptions in a final settlement for the same cost-reporting period.

NOV 29 2019 TN No. 10-006 Approval Date: SUPERSEDES TN No. 09-027 Effective Date: 07-01-2010

Attachment 4.19 - A

5101:3-2-23 3

(1) If an amended medicare cost report is filed with the medicare fiscal intermediary, a copy of the amended medicare cost report must be filed with the hospital audit section. Information contained in the amended medicare cost report will be incorporated into the interim cost report, as originally filed, if received prior to interim settlement; otherwise, it is subject to the provisions of paragraph (F) of this rule.

(2) Adjustments may be made to the interim cost report as described in rule 5101:3-2-24 of the Administrative Code.

(G) Out-of-state providers that are not paid on a prospective payment basis and provide inpatient and/or outpatient services to eligible Ohio Title XIX recipients will be required to file the cost report identified in this rule.

(H) Hospitals that fail to submit cost reports timely as defined in paragraph (A) of this rule will receive a delinquency letter from the ODJFS and are subject to notification that thirty days following the date on which the cost report was due, payments for hospital services will be suspended. Suspension of payments will be terminated on the fifth working day following receipt of the delinquent cost report. Claims affected by suspension of payment are not considered to be clean claims as "clean claims" are defined in rule 5101:3-1-19.3 of the Administrative Code. At the beginning of the third month following the month in which the hospital cost report became overdue, if the cost report has not yet been submitted, termination of the provider from the program will be recommended in accordance with Chapter 5101:3-1 of the Administrative Code.

NOV 29 2010

TN No. 10-006 Approval Date: SUPERSEDES

TN No. 09-027 Effective Date: 07-01-2010

5101:3-2-23

Effective:

R.C, 119.032 review dates:

Attachment 4.19 - A

09/01/2012

Certification

Date

Promulgated Under: Statutory Authority: Rule Amplifies:

Prior Effective Dates:

119.03

5111.02

5111.02, 5111.021

4/7/77, 12/30/77, 3/21/81, 11/11/82, 1/1/84, 10/1/84, 7/29/85, 10/1/85 (Emer), 12/22/85, 10/19/87, 4/23/88, 8/1/88 (Emer), 10/21/88, 2/22/89 (Emer), 5/8/89, 11/5/89, 5/25/90, 5/1/91, 5/1/92, 10/1/93 (Emer), 11/15/93, 1/20/95, 3/16/96, 7/1/96, 7/1/97, 4/26/99, 7/15/99, 10/18/99, 5/1/00, 5/17/01, 3/27/03, 7/17/03, 9/2/04, 9/17/05, 11/9/06, 9/17/07, 7/17/08, 2/26/10

NOV 29 2010 TN No. 10-006 Approval Date: SUPERSEDES TN No. 09-027 Effective Date: 07-01-2010

ACTION: Original

ENACTED Appendix 5101:3-2-23

DATE: 06/30/2010 143M" }"?~*

Page 1 of 52

Ohio Department of Job and Family Services

JFS 02930-I (Rev. 4/2010)

HOSPITAL COST REPORT (JFS 02930)

INSTRUCTIONS

For State Fiscal Year 2010

NOV 29 2010 TN No. 10-006 Approval Date: SUPERSEDES

APPENDIX p(64177) put 114139) 292947) ral240470)

TN NO. 09-027 Effecthwe Rater GsOir2010

Attachment 4.19 - A

Page 2 of 52

Table of Contents

GENERAL INSTRUCTIONS. FILING DEADLINE...... REQUIRED FILINGS FILING EXTENSIONS... AMENDED FILINGS... IMPORTANT REMINDE! CHANGES

SCHEDULE A

SCHEDULE B

SCHEDULE C

SCHEDULE C-1.

SCHEDULE C-2.

SCHEDULE D...

SCHEDULE D-1

SCHEDULE E.......cccsssscsssessscsssessessscssensssassscceceesecsessccessesecesaonseeseaneuseuscseuseussseesacuaassusereeseussusansene 15

SCHEDULE F INDEPENDENT THIRD PARTY VALIDATION OF SCHEDULE F DATA. GENERAL INSTRUCTIONS (APPLIES TO ALL OF SECTION 1)........... SECTION I (UNCOMPENSATED CARE FOR ACUTE CARE HOSPITALS)..

Instructions for Column 1 Instructions for Column 2.. “ Instructions for Column 3..... 22 Instructions for Columns 4 and 5. Instructions for Column 6.. . Instructions for Column 7.......0.++. 24 SECTION II (FREE-STANDING PSYCHIATRIC HOSPITAL INFORMATION) ..

SCHEDULE G

SCHEDULE H..

SCHEDULE 1 .......04.

Wonuadbda RWWW

NOV 29 2010

TN No. 10-006 Approval Date: IFS 02930-I (Rev. 4/2010) ae Effective Date:

Attachment 4.19 - A

Page 3 of 52 GENERAL INSTRUCTIONS

Please read and follow all instructions carefully. Instructions that pertain to DRG-exempt and out-of-state hospitals will be in italics throughout the cost report instructions. If you have questions about the instructions or report please contact Jeff Runkle of the Rate Setting & Cost Settling Unit, (614) 752-4427.

The cost report schedules should be completed in order, from A to I. Within the report, the line numbers for the revenue centers are set up to closely match the CMS-2552-96 in order to allow for easy transfer of data.

UB-92 revenue center codes should be grouped as shown on the attached sheets for inpatient and outpatient services. If this is not possible YOU MUST specifically identify any differences in groupings on the enclosed BILLING CODE ALLOCATION sheet(s) and return them with the completed cost report. When differences in groupings exist but are not identified by the report filer, ODJFS groupings will be used at the time of settlement.

Report only data and discharges occurring within the fiscal period covered by this cost report. FILING DEADLINE

Rule 5101:3-2-09, of the Ohio Administrative Code states in part “...any hospital that fails to report the information required under this rule on or before the dates specified in this rule and in rule 5101:3-2-23 of the administrative code shall be fined one thousand dollars ($1,000.00) for each day after the due date that the information is not reported.”

The completed cost report MUST BE POSTMARKED on or before June 30, 2010 for those hospitals filing with a cost reporting period ending between July 1, 2009 and December 31, 2009. For

those hospitals filing with a cost report period ending between January 1, 2010 and June 30, 2010, the report is to be postmarked no later than December 31, 2010.

TIRED FILIN

Your completed cost report filing MUST indude:

- the completed CMS-2552-96 electronic cost report (EC) and print image (PI) files ~ all completed applicable JFS 02930 schedules

- Email the CMS-2552-96 (EC & PI files) and JFS 02930.xIs to: hospital_cost_reports@jfs.ohio.gov If unable to email, please contact ODJFS.

- Mail the following cost report information to:

Via Regular Mail (preferred) Via Parcel Carriers (not required) Ohio Health Pians Ohio Health Plans

Rate Setting & Cost Settling Unit Rate Setting & Cost Settling Unit P.O. Box 182709 50 W. Town Street, Ste 400, 4" Floor Columbus, OH 43218-2709 Columbus, OH 43215-4142

An original SIGNED JFS 02930 Certification Page A hard copy of the JFS 02930 schedules and OBRA Survey A copy of the SIGNED CMS-2552-96 Certification Page

- Remittance for amounts due with copy of settlement page should be mailed to: Ohio Department of Job and Family Services P.O. Box 182367, Columbus, OH 43218-2367

- Make checks payable to: Treasurer of State, State of Ohio (ODJFS) Nov 29 2010 TN No. 10-006 Approval Date: IFS 02930-I (Rev. 4/2010) SUPERSEDES

TN No. 09-027 Effective Date: 07-01-2010

Attachment 4.19 - A

Page 4 of 52

Requests for an extension of the filing deadline, for no more than one 30 day period, must be made in advance, in writing, to Ohio Health Plans, Cost Reporting Unit, P.O. Box 182709, Columbus, OH 43218- 2709.

If Medicare grants an extension that would go beyond the above one-time 30 day extension, documentation must be provided. Please submit your request in writing to the above address and include a copy of the Medicare extension letter. The filing deadline will be 30 days after the required filing date of the Medicare Cost Report. No further extensions will be granted.

AMENDED FILINGS

Amended CMS-2552-96 reports filed by hospitals with the Medicare intermediary must also be filed with ODJFS. No amendments to the JFS 02930 will be accepted later than 30 days after the hospital's receipt of the audited interim settlement.

IMPORTANT REMINDERS

The Upper Limit Payments (UPL) payments reported on Schedule H, col. 1, line 5 should be recorded gross, not net.

The OBRA Survey must be completed in its entirety.

Out-of-State providers that are paid on a prospective payment basis are NOT required to file a cost report.

Hospitals are provided with Interim Paid Claims data Indicating paid Medicaid Fee-for-Service daims through the date specified on the report. This information is provided as a courtesy to hospitals. Each hospital is expected to use its own accounting/ patient information system to complete the cost report.

CHANGES © The cost report instructions and forms have been updated to reflect dates and filing deadlines relevant to the SFY 2010 Reporting Periods.

© Text has been added to Schedules D and I to provide guidance on when daim charges should be included on those schedules.

NOV 29 wi

TN No. 10-006 Approval Date: JFS 02930-I (Rev. 4/2010) avstalaarabet Effective Date

Attachment 4.19-A

Page 5 of 52

SCHEDULE A

MISCELLANEOUS REVENUES

Note - Throughout the JFS 02930 cost report instructions "Worksheet" refers to Medicare's CMS- 2552-96 and "Schedule" refers to the JFS 02930.

Lines 1 - 24 - Enter all amounts included on Worksheet G-2 which are not included on the Worksheet C, column 8. Examples may include, but are not limited to: Home Health, Hospice, Organ Acquisition, Professional Fees (detailed by cost center), etc.

NOV 22 29 TN No. 10-006 Approval Date: JPS 02930-I (Rev. 4/2010) urersees rffective Date

Attachment 4.19 - A

Page 6 of 52

SCHEDULE B

COST DISTRIBUTION

Column 1

Lines 25-34, 37-97, and 100 - Enter total cost figures from Worksheet C, Part I, column 5 for each revenue center. Note: Report costs for Organ Acquisition, Hospice, and Home Health Agency from Worksheet B, part I, column 27. For free-s 2 2 k rt cos

Line 100 - Enter Observation Bed costs only if these costs are induded both on line 25 and on line 62.

Column 2

Lines 25-34 and 37-97 - Enter all Interns and Residents costs that were removed from total cost reported on Worksheet B part I, column 26. Include drug costs related to Renal Dialysis or Home Program Dialysis that were also removed from total costs.

Column 3

Lines 25 - 97 - Enter the total of columns 1 and 2.

Column 4

For any revenue center that has costs but no corresponding charges, enter a charge of one dollar ($1.00).

Lines 25-97 - Record total charges from Worksheet C, part I, column 8.

Line 100 - Enter one dollar ($1.00) if an amount is entered in column 3, line 100.

Lines 25-34, 37-97, and 100 ~ Divide each line amount in column 3 by the corresponding line amount in column 4 and enter the result rounded to six decimal places.

Column 6

Lines 25-34 and 37-97 - Enter the total allowable inpatient charges from Worksheet C, part I, column 6 for each revenue center. (Note: Subprovider services reimbursed on a cost basis by Medicare but reimbursed by Medicaid on the DRG system must be included in this column; i.e., Distinct Part Psychiatric services. Do not enter data for those revenue centers not eligible for cost reimbursement or DRG payment, e.g. Home Health Agency, SNF, Hospice, Ambulance, residential treatment).

Column 7 Lines 25-34, 37-97, and 100 - Multiply the charges in column 6 by the corresponding ratio in column 5. Enter the result rounded to the nearest dollar.

Column &

Lines 25-34 and 37-97 - Enter the total allowable outpatient charges from Worksheet C, part I, column 7 for each revenue center. Do not include amounts for those revenue centers previously not eligible for cost reimbursement, i.e., Outpatient Laboratory, S.N.F. Ancillary, Hospice, Home Health Agency, and Ambulance.

NOV 29 20V TN No. 10-006 Approval Date:

JFS 02930-I (Rev. 4/2010) eisai effective Date: ;

Attachment 4.19 -A

Page 7 of 52

Column 9 Lines 25-34 and 37-97 - Multiply the charges in column 8 by the corresponding ratio in column 5 and enter the result rounded to the nearest dollar.

Column 10 Lines 25-34 and 37-97 - Enter charges for revenue centers that are not eligible for cost reimbursement, i.e., Outpatient Laboratory, S.N.F. Ancillary, Hospice, Home Health Agency, and Ambulance.

Column 11 Lines 25-34 and 37-97 - Multiply the charges in column 10 by the corresponding ratio in column S and enter the result rounded to the nearest dollar.

Columns 1-11

Line 35 - Enter the total of lines 25 through 34. Line 98 - Enter the total of lines 37 through 97. Line 99 - Enter the total of lines 35 and 98.

Line 101 - Enter the total of line 99 less line 100.

NOV 29 aw

TN No. 10-006 Approval Date: IFS 02930-I (Rev. 4/2010) ANN ao tp? effective Date: 07-01:

Attachment 4.19 - A

Page 8 of 52

SCHEDULE C

CALCULATION OF ROUTINE COSTS

Column 1 - Transfer amounts from Schedule B, column 7, lines 25-33 to the appropriate lines. Enter the sum of lines 25-33 on line 35.

Column 2 - Swing Beds - Transfer to line 25 the amount on Worksheet D-1, part I, line 26 as negative amounts. Enter the sum of lines 25-33 on line 35.

Column 3 - For each line enter the sum of columns 1 and 2. Enter the sum of lines 25-33 on line 35.

Solumn 4 ° Enter the total days from Worksheet S-3, path L column 6 to the appropriate in lines. Itthere are

For Observation Bed days assigned directly to a ‘subprovider, those days should be included with the subprovider’s days rather than | in Adults & Pediatric line 25. Do not indude swing bed days. For

lines 25- 33 on line 35.

Column 5 - Divide each line amount in column 3 by the corresponding days in column 4 for lines 25-33 and enter the result rounded to two decimal places.

Column 6 - For each revenue center, enter the number of covered days of service rendered to Title xx patients Gscharged during t the reporting period. »

reasonable cost basis), Enter the id on.a DE lines 25- 33 on line 35.

Column 7 - For each revenue center, multiply the per diem calculated in column 5 by the XIX days reported in column 6 and enter the result rounded to the nearest dollar. Enter the sum of lines 25-33 on line 35.

Column 8 - For each revenue center, enter the number of covered days of service rendered to Title V patients discharged during the reporting period. S B s days. Enter the sum of lines 25-33 on line 35.

Column 9 - For each revenue center, multiply the per diem calculated in column 5 by the Title V days reported in column 8 and enter the result rounded to the nearest dollar. Enter the sum of lines 25-33 on line 35.

Column 10 - For each revenue center, enter the number of covered days of service rendered to Title XIX vansplant ape eariag erika the reporting period. Include only tansplant services paid on a

Enter the sum of lines 25°33 on line 35.

Column 13 - For each revenue center, multiply the per diem calculated in column 5 by the Title XIX transplant days reported in column 10 and enter the result rounded to the nearest dollar. Enter the sum of lines 25-33 on line 35.

NOV 29 2010 TN No. 10-006 Approval Date: IFS 02930-I (Rev. 4/2010) eeaiasaed effective Date: ;

Attachment 4.19 - A

Page 9 of 52

SCHEDULE C-1

DISCHARGE STATISTICS As defined in Ohio Administrative Code, rule 5101:3-2-02 (B)(17): A patient is said to be “discharged” when he or she:

(a) Is formally released from a hospital

(b) Dies while hospitalized

(c) Is discharged, within the same hospital, from an acute care bed and admitted to a bed in a psychiatric unit distinct part as described in paragraph(B)(8) of this rule or is discharged within the same hospital, from a bed in a psychiatric unit distinct part to an acute care bed;

(d) Signs self out against medical advice (AMA).

The discharges reported on this schedule should also include the number of patients transferred to other facilities,

SECTION I

Column 3 - Enter, from Worksheet S-3, part I, column 15, the number of discharges for each revenue center. Enter the sum of lines 36-39 on line 40. Although Total Facility Nursery Discharges are not detailed on Worksheet S-3, part I, please report Total Facility Nursery Discharges as maintained in your records.

Columns 2-4 - Enter the number of discharges from the facility for program patients. Title XIX services are classified by various rate years. Your fiscal year may not include every category. Only report discharges into the category ¢ that Bt corresponds with your fiscal year. Enter the s sum of each column on line 40.

Column 2-4, line 44 - Enter your capital add-on rate for the periods for which you reported discharges.

Columns 7 & 8 - Enter the number of discharges from the facility for Medicaid HMO enrolled patients. Medicaid HMO services are classified by various rate years. Your fiscal year may not indude every category.

Only report discharges into the category that corresponds with your fiscal year. Enter the sum of each column on line 40.

SECTION II

Outpatient visits should be counted as the number of final outpatient claims for which a hospital was paid and/or expects to receive payment. Series accounts/cycle bills should be counted as 1 visit per claim (not the number of dates of service on that claim). Observation and emergency services aims should be counted as outpatient visits unless these visits tured into inpatient admissions on the same date of service.

Line 42, column 1 - Enter the number of total facility outpatient visits.

Line 42, column 2 - Enter the number of Medicaid outpatient visits on or before 12/31/07. NOV 29 2010 TN No. 10-006 Approval Date: JFS 02930-I (Rev. 4/2010) SUPERSEDES TN No. 09-027 Effective Date: 07-01-2010

Attachment 4.19 - A

Page 10 of 52 Line 42, column 3 ~ Enter the number of Medicaid outpatient visits on or after 1/1/08. SECTION III Line 43 - Enter as a sum, the number of beds on Worksheet S-3, part I, column 1, lines 12 and 14.

Line 44 - Enter as a sum, the net number of interns and residents in an approved teaching program on Worksheet S-3, part I, column 9, lines 12, and 14.

Nov 29 2010 TN No. 10-006 Approvai Date:

JFS 02930-I (Rev. 4/2010) iraialabem effective Date: 07-01:

Attachment 4.19 - A

Page 11 of 52

SCHEDULE C-2

MEDICAID HMO INPATIENT DAYS SECTION I Column 1 — Enter the per diem amounts from Schedule C, column 5, for each cost center in Lines 25 - 33.

Column 2 — For each revenue center, enter the number of covered days of service rendered to Medicaid HMO patients discharged during the reporting period. Enter the sum of lines 25-33 on line 35.

Column 3 ~ For each revenue center, multiply the per diem calculated in column 5 by the Medicaid HMO days reported in column 3 and enter the result rounded to the nearest dollar. Enter the sum of lines 25-33 on line 35.

NOV 29 2010 TN No. 10-006 Approval Date: JFS 02930-1 (Rev. 4/2010) Wie ep Effective Date

Attachment 4.19 - A

Page 12 of 52

SCHEDULE D

TITLE XIX COST CALCULATIONS

Include charges for the following;

* Patients whose primary coverage was Ohio Medicaid Fee-for-Service and a payment was received directly from the Ohio Department of Job and Family Services.

= Patients whose Ohio Medicaid Fee-for-Service coverage was secondary to other insurance, (e.g. Blue Cross, Aetna, Railroad, etc.) and a payment was received from both the Primary Insurer and the Ohio Department of Job and Family Services.

« Patients whose Ohio Medicaid Fee-for-Service coverage was secondary to other insurance, (e.g. Blue Cross, Aetna, Railroad, etc.) and a payment was received from only the Primary Insurer and the claim was reported as “paid” on the Ohio Department of Job and Family Services remittance advice.

= Patients for any of the above situations for which you have submitted a daim and reasonably expect to receive a payment from the payer.

Do Not Include charges for patients enrolled in Medicare or a Medicare Advantage Pian as Ohio Medicaid only pays cost sharing (coinsurance and/or deductible) for these claims.

Hospitals are provided with Interim Paid Claims data indicating paid Medicaid Fee-for-Service daims through the date specified on the report. This information is provided as a courtesy to hospitals. Each hospital is expected to use its own accounting/ patient information system to complete the cost report.

Column i - Enter the ratio from Schedule B, column 5, for each revenue center on the corresponding line.

Column 2 Lines 25-33 and 37-97 - Enter the charges fo for covered Title XIX X inpatient services rendered during the

Column 3 Lines 25-33 - Transfer the cost amounts from Schedule C, column 7, lines 25 to 33.

Lines 37-97 - Multiply the charges in column 2 by the corresponding ratio in column 1. Enter the result rounded to the nearest dollar.

Lines 25-33 -

Lines 37-97 - Enter the charges for covered outpatient services. Do not include charges for Outpatient Laboratory Services, or any services which are not cost settled, (e.g., Pregnancy services).

Column 5 Lines 25-33 and 37-97 - Multiply the charges in column 4 by the corresponding ratio in column 1. Enter the result rounded to the nearest dollar.

Column 6 Lines 41-44 and 70-97 - Enter the charges for Outpatient Laboratory Services.

Column 7

Lines 41-44 and 70-97 - Multiply the charges in column 6 by the corresponding ratio in column 1. Enter

the result rounded to the nearest dollar. NOV 29 20:9 TIN No. 10-006 Approval Date: '

IFS 02930-I (Rev. 4/2010) NN ao op Effective Date . 09-027 Effective Date: 07-01-2010

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Column §

Lines 25-33 and 37-97 - Report only allowable charges for transplant services that are reimbursed on a reasonable cost basis during the reporting period.

Column 9

Lines 25-33 - Transfer the cost amounts from Schedule C, column 11, lines 25-33.

Lines 37-97 - Multiply the charges in column 8 by the corresponding ratio in column 1. Enter the result rounded to the nearest dollar.

Line 35 - Enter the total of lines 25 through 33.

Line 98 - Enter the total of lines 37 through 97.

Line 101 - Enter the total of lines 35 and 98.

HOV 29 ai TN No. 10-006 Approval Date:

JFS 02930-I (Rev. 4/2010) upersenes Effective Date

Attachment 4.19 - A

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SCHEDULE D-1

TITLE V COST CALCULATIONS

Column 1 Lines 25-33 and 37-97 - Transfer total cost amounts from Schedule B, column 3, to the corresponding lines.

Column 2 Lines 25-33 and 37-97 - Enter the amount of cost associated with combined billing of provider based physician professional services as reported on Worksheet A-8-2, column 4.

Column 3 Lines 25-33 and 37-97 - Enter the sum of columns 1 and 2.

Column 4 Lines 25-33 and 37-97 - Transfer the total charge amounts from Schedule B, column 4, to the corresponding lines.

Column 5 Lines 25-33 and 37-97 - Enter the amount of charges associated with the costs of combined billing of provider based physician professional services that are reported in column 2.

Column 6 Lines 25-33 and 37-97 - Enter the sum of columns 4 and 5.

Column 7 Lines 25-33 and 37-97 - Divide column 3 by column 6 and enter the resulting ratio, rounded to six decimal places, for each cost center.

Column 8

Lines 25-33 and 37-97 - Enter the charges for covered inpatient Title V services rendered during the cost reporting period.

Column 9

Lines 25-33 - Transfer the cost amounts from Schedule C, column 9.

Lines 37-97 - Multiply the charges in column 8 by the corresponding ratio in column 7. Enter the result rounded to the nearest dollar.

Column 10 Lines 25-33 and 37-97 - Enter the charges (indluding Outpatient Laboratory and Radiology services for covered outpatient Title V services) rendered during the reporting period.

Column 11 Lines 25-33 and 37-97 - Multiply the charges in column 10 by the corresponding ratio in column 7. Enter the result rounded to the nearest dollar.

Columns 1-11 Line 35 - Enter the total of lines 25 through 33.

Line 98 - Enter the total of lines 37 through 97.

Line 101 - Enter the total of lines 35 and 98. hOV 29 29

TN No. 10-006 Approval Date: JFS 02930-I (Rev. 4/2010) urERsepes effective Dat

Attachment 4.19 - A

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SCHEDULE E

MEDICAL EDUCATION COSTS AND MISCELLEANOUS DATA

MEDICAL EDUCATION COSTS

Line 1 — Enter the amount from Worksheet B, part I, column 20 — 20.XX, line 95.

Line 2 — Enter the amount from Worksheet B, part I, column 21 — 21.XX, line 95.

Line 3 — Enter the amount from Worksheet B, part I, columns 22 ~ 22.XX and 23 — 23.XX, line 95. Line 4 — Enter the amount from Worksheet B, part I, column 24 ~ 24.XX, line 95.

Line 5 — Enter the total of lines 1 through 4.

XIX OUTPATIENT LAB PAYMENTS Line 6 - Enter the total Title XIX Outpatient Lab payments received that relate to charges reported on Schedule D, column 6, line 44,

NET PATIENT REVENUES | SECTION 1011 PAYMENTS

Line 7a — Enter the Net Patient Revenue amount from Worksheet G-3 line 3.

Line 7b — Enter the amount received for services provided under Section 1011 — Federal Reimbursement of Emergency Health Services Furnished to Undocumented Allens. For additional information regarenn9 Section 1011, please visit the = following websites; H h ]

NOV 29 s:9 TN No. 10-006 Approval Date:

IFS 02930-1 (Rev. 4/2010) esate Effective Date: 07-01-2

Attachment 4.19 - A

Page 16 of 52

SCHEDULE F HOSPITAL CARE ASSURANCE UNCOMPENSATED CARE

OUT-OF-STATE HOSPITALS SHOULD NOT COMPLETE THIS SCHEDULE. OHIO ACUTE CARE HOSPITALS SHOULD COMPLETE SECTION I PSYCHIATRIC HOSPITALS SHOULD COMPLETE SECTION IT

INDEP THIRD P. Vv ATION HEDULE F DATA

Effective for Medicaid Cost Reports filed for cost reporting periods ending in State Fiscal Year (SFY) 2003, and each cost reporting period thereafter, each hospital, shall be required to have an independent party, external to the hospital, verify the data reported on Schedule F. The external reviewer shail at a minimum perform the data verification based on a set procedure as follows.

1. Verify that patient logs are maintained for the following categories of patients: e Disability Assistance inpatient charges, with insurance Uncompensated care inpatient charges < 100% federal poverty income limits (FPL), with insurance Disability Assistance outpatient charges, with insurance Uncompensated care outpatient charges < 100% FPL, with insurance Disability Assistance inpatient charges, with no insurance Uncompensated care < 100% FPL, inpatient charges, with no insurance Uncompensated care > 100% FPL, inpatient charges, with no insurance Disability Assistance outpatient charges, with no insurance Uncompensated care < 100% FPL, outpatient charges, with no insurance Uncompensated care > 100% FPL, outpatient charges, with no insurance

2. Verify that the Hospital's patient logs include a date-of-service. Verify that the service dates for accounts with Disability Assistance coverage or family income < 100% FPL are recorded in the cost report period in which they occurred, and that the write-off dates for accounts with family incomes >100% FPL, are recorded in the cost report period in which they were written-off. Verify that each log entry includes a unique (unduplicated) identifier for the patient, that is unique to the patient and not to each visit by the patient.

3. Verify that the supporting patient log totals for the data elements listed below agree to each data element on the Hospital's JFS 02930 Schedule F. If any of the elements do not match, return the patient logs to Hospital for correction. e Line 8, Columns 1 and 6 — Disability Assistance inpatient charges and receipts, with insurance e Line 9, Columns 1 and 6 — Uncompensated care < 100% FPL inpatient charges and receipts , with insurance Line 12, Columns 1 and 6 — Disability Assistance, outpatient charges and receipts, with insurance Line 13, Columns 1 and 6 — Uncompensated care < 100% FPL, outpatient charges and receipts, with insurance Line 8, Columns 2 and 7 — Disability Assistance, inpatient charges and receipts, with no insurance e Line 9, Columns 2 and 7 — Uncompensated care < 100% FPL, inpatient charges and receipts , with no insurance e Line 10, Columns 2 and 7 — Uncompensated care > 100% FPL, inpatient charges and receipts, with no insurance Line 12, Columns 2 and 7 — Disability Assistance outpatient charges and receipts, with no insurance Line 13, Columns 2 and 7 - Uncompensated care < 100% FPL, outpatient charges and receipts, with no insurance e Line 14, Columns 2 and 7 — Uncompensated care > 100% FPL, outpatient charges and receipts, with no insurance

noy 2g wd TN No. 10-006 Approval Date:

JFS 02930-I (Rev. 4/2010) bettered Effective Date: 07 . 09-027 Effective Date: 07-01-2010

Attachment 4.19 -A

Page 17 of 52

4. Verify the mathematical accuracy of Hospital's logs, by using at least the methodologies described below. If the logs were totaled manually, request adding machine tapes and match a sample of 10 entries on two of the tapes to the corresponding entries on the patient logs. If the logs were totaled with the use of an electronic spreadsheet, verify the accuracy of the formula(s) used. If the log entries were taken directly from the hospital's mainframe computer system, select one of the categories in Step 3 and tally the entries. If the logs do not foot, return the logs, and, if appropriate, the tapes to Hospital for correction.

5. From the hospital logs, select a random sample of entries from each of the ten data elements listed in Step 3, and verify the appropriateness of the write-off. The appropriateness of the write-off for each account selected shall be determined in accordance with Ohio Administrative Code (OAC) 5101:3-2-07.17 and the hospital's policies regarding the documentation of applicants’ incomes.

The size of the required sample will vary according to which of three tiers the Hospital is placed in, using data from the current cost reporting period:

¢ If the hospital reports total uncompensated care charges for patients without insurance that is less than $5.0 million, the size of the sample shall be at a minimum, 32 accounts: four in each of the six data categories identified in Step 3 for patients with no insurance and two in each of the categories for patients with insurance.

© If the hospital reports total uncompensated care charges for patients without insurance that is greater than $5.0 million but less than $10.0 million, the size of the sample shail be at a minimum, 64 accounts: eight in each of the six data categories identified in Step 3 for patients with no insurance and four in each of the categories for patients with insurance.

e If the hospital reports total uncompensated care charges for patients without insurance that is greater than $10.0 million, the size of the sample shall be at a minimum, 96 accounts: 12 in each of the six data categories identified in Step 3 for patients with no insurance and six in each of the categories for patients with insurance.

e In addition to the above sample criteria, review all accounts for patients in the uncompensated care < 100% FPL, with no insurance categories which show receipts.

6. Obtain itemized statements from the Hospital for each of the patient accounts identified in the random selection of data elements identified in Step 5. Match the itemized statement to its corresponding entry in Hospital's log. Verify that patient accounts were correctly logged and entered in Schedule F, based on insurance status.

From the itemized statement, verify the patient's name, the date(s) of service, and whether the account is inpatient or outpatient and corresponds with the log entry. Subtract from the itemized statement any charges for services that can not be counted as “basic, hospital level" as described in OAC 5101:3-2-07.17 and OAC 5101:3-2-02, Appendix A. Verify that the sum of any subtraction of non-hospital level charges matches or does not exceed the entry for gross charges in Hospital's log. Verify that the total of all receipts on each selected account matches the receipts shown in the Hospital's log.

7. Obtain a copy of the Hospital's internal policy outlining its procedures for documenting applications for HCAP qualifying charity care or write-off.

8. Obtain copies of the documentation the Hospital used to determine eligibility for each of the patient accounts identified in the random selection of data elements identified in Step 5. Verify that the hospital's

documentation practices are supported by its policy statement, obtained in Step 7, and are in accordance with OAC 5101:3-2-07.17.

9. From the eligibility documentation outlined in Step 8, verify that the patients were residents of Ohio, and

not eligible for Medicaid according to OAC 5101:3-2-07.17. Verify that the patient accounts logged as eligible

for Disability Assistance (DA) were in fact eligible for DA on the date(s) of service. For accounts of patients

<100 % FPL, verify that Hospital used the appropriate Federal Poverty Income Guidelines that were in effect

for the date(s) of service, and verify that the patient's income and family size on the date(s) of service were

correctly calculated according OAC 5101:3-2-07.17. HOY 29 125 i dad

TN No. 10-006 Approval Date: IFS 02930-I (Rev. 4/2010) Beataaroed ef Date:

Attachment 4.19 - A

Page 18 of 52

10. Request a list of pending-Medicaid accounts from Hospital. Verify that no accounts that have been approved for Medicaid were included in any log or Schedule F entry.

11. The external reviewer shall issue a review report to the hospital.

The hospital must respond to the external reviewer with a written report which indudes a course of corrective action taken by the hospital.

Re-verification of Schedule F Changes

Any hospital that submits an amended cost report that Includes changes to data reported on Schedule F shall be required to have an independent CPA re-verify the data reported on Schedule F. The external reviewer shall, at a minimum, perform the data verification as follows:

1, When making wholesale changes, including reassigning amounts between write-off categories, the entire Schedule F data shall be reviewed as specified in step 5.

2. If only new accounts are added and no other changes to Schedule F are made, then the CPA shall select and review at least 5% of new accounts from each category in accordance with the review procedures steps 6 through 9. If the number of accounts to be reviewed under the 5% criteria exceeds the original sample size, then the entire Schedule F data shall be reviewed as specified in step 5.

External Data Validation R

Each hospital shall retain all Schedule F data validation review reports for every cost report year, induding recertification review reports and hospital responses to auditor reports, for a period of three years, and shall make such reports available to the department upon request, within three business days of such request.

GENERAL IN NS (APPLIES TO ALL OF SE N 1):

Only discharges/visits and charges for hospital services may be included in Schedule F. Indude only “Basic, medically necessary hospital level services” which are considered services in Appendix A of rule 5101:3-2-02 of the Ohio Administrative Code. Do not include charges related to physidans’ services, transportation services, or take-home pharmacy items, and do not indude visits to free standing clinics or surgery centers that are not hospital based. Do not indude any portion of a patient account for a Medicaid recipient, regardless of whether the recipient is enrolled in an HMO or Medicaid fee-for-service. Do not include discharge/visits and charges that have been written off as Medicare bad debts.

Report uncompensated care information for patients with insurance in Column 1. Report uncompensated care information for patients without insurance in Column 2. Schedule F does not include a column for reporting total uncompensated care; it will be calculated by the department. Include any charges, inpatient discharges, and outpatient visits for patients eligible for “Hill-Burton” or covered by a local levy fund. Do not consider any Hill-Burton write-off or any payment by a local health care levy to be “insurance.”

In both Column 6 and 7 the amount reported in lines 8 through 15 must equal all payments you have either received or reasonably expect to receive from these patients or their insurers. For patients below poverty without insurance, rule 5101:3-2-07.17 of the Ohio Administrative Code requires that these patients receive care free of charge. There are very few circumstances which allow you to accept receipts for these accounts.

The data on uncompensated care for people on Disability Assistance in lines 8 and 12, and the

data on uncompensated care for patients with family incomes below federal poverty guidelines

in lines 9 and 13, may only include inpatient and outpatient accounts with discharge/ visit dates

that fall within your hospital's fiscal year. You must split-bill any outpatient accounts which cross ne V 29 ih} ~

TN No. 10-006 Approval Date: IFS 02930-1 (Rev. 4/2010) Batnlaronbed gE Date: 07

iui

Attachment 4.19 - A

Page 19 of 52

dates. Uncompensated care for patients with family incomes above federal poverty income guidelines may be included in lines 10 and 14 regardless of the service dates, so long as the date of the bad debt or charity care write-off fell within your hospital's fiscal year, and had not been previously written off.

PENSATE FOR At RE HOSPITA\ Instructions for Column 1

COLUMN 4 Information in Column 1 should indude data for patients who have received uncompensated care for some portion of their inpatient discharge or outpatient visit that was also covered by health insurance for the services provided.

GROSS INPATIENT CHARGES

Line 8; Total DA Charges for Patients with Insurance - INPATIENT Enter the gross charges for inpatient discharges by eligible Disability Assistance recipients, who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 9: Total UC Charges for Patients Below 100% with Insurance - INPATIENT

Enter the gross charges for inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 10: Total UC Charges for Patients Above 100% with Insurance - INPATIENT

Enter the gross charges for inpatient discharges for patients with family incomes above the federal poverty income guidelines, and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 11; Total Uncompensated Care Charges for Patients with Insurance - INPATIENT Enter the total of lines 8 through 10.

GROSS OUTPATIENT CHARGES

Line 12: Total DA Charges for Patients with Insurance — OUTPATIENT Enter the gross charges for outpatient visits by eligible Disability Assistance recipients, who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 13; Total UC Charges for Patients Below 100% with Insurance — OUTPATIENT

Enter the gross charges for outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, during your hospital’s fiscal year.

Line 14: Total UC Charges for Patients Above 100% with Insurance — OUTPATIENT

Enter the gross charges for outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of The Ohio Administrative Code, who had some form of insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital’s fiscal year. Recipients of Medicaid in any other state can not be included of Schedule F.

Line 15: Total Uncompensated Care Charges for Patients with Insurance — OUTPATIENT Enter the total of lines 12 through 14. NOY 29 i iis TN No. 10-006 Approval Date: JFS 02930-I (Rev. 4/2010) SUPERSEDES TN No. 09-027 Effective Date: 07-01-2010

Attachment 4.19 - A

Page 20 of 52 INPATIENT DISCHARGES

Line 16; Total DA Inpatient Discharges for Patients with Insurance Enter the number of inpatient discharges for Disability Assistance patients who also had some form of insurance for the services delivered during your hospital's fiscal year.

Line 17; Total UC Inpatient Discharges for Patients Below 100% with Insurance

Enter the number of inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the service delivered, during your hospital's fiscal year.

Line 18; Total UC Inpatient Discharges for Patients Above 100% with Insurance

Enter the number of inpatient discharges for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of The Ohio Administrative Code, which had some form of insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be induded on Schedule F.

Line 19; Total UC Inpatient Discharges for Patients with Insurance Enter the total of lines 16 through 18.

OUTPATIENT VISITS

Line 20: Total DA Outpatient Visits for Patients with Insurance Enter the number of outpatient visits for Disability Assistance patients who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 21; Total UC Outpatient Visits for Patients Below 100% with Insurance

Enter the number of outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the service delivered, during your hospital's fiscal year.

Line 22: Total UC Outpatient Visits for Patients Above 100% with Insurance

Enter the number of outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which had some form of insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 23: Total UC Outpatient Visits for Patients with Insurance Enter the total of lines 20 through 22.

Instructions for Column 2

COLUMN 2 Information in Column 2 should include data for patients who have received uncompensated care and do not have any insurance for the services provided.

GROSS INPATIENT CHARGES

Line 8; Total DA Charges for Patients without Insurance — INPATIENT Enter the gross charges for inpatient discharges by eligible Disability Assistance recipients, who did not have insurance for the services delivered, during your hospital's fiscal year.

WOY 29 wait TN No. 10-006 Approval Date: IFS 02930-I (Rev. 4/2010) TN No 09-037 Effective Date: 07-01-2010 lo. e Is o

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Page 21 of 52

Line 9; Total UC Charges for Patients Below 100% without Insurance — INPATIENT

Enter the gross charges for inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 10; Total UC Charges for Patients Above 100% without Insurance — INPATIENT

Enter the gross charges for inpatient discharges for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, who did not have insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital's fiscal year. Redipients of Medicaid in any state can not be included on Schedule F.

Line 11; Total Uncompensated Care Charges for Patients without Insurance — INPATIENT Enter the total of lines 8 through 10.

GROSS OUTPATIENT CHARGES

Line 12; Total DA Charges for Patients without Insurance —- OUTPATIENT Enter the gross charges for outpatient visits by eligible Disability Assistance recipients, who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 13: Total UC Charges for Patients Below 100% without Insurance — OUTPATIENT

Enter the gross charges for outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 14; Total UC Charges for Patients Above 100% without Insurance — OUTPATIENT

Enter the gross charges for outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, who did not have insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 15; Total Uncompensated Care Charges for Patients without Insurance — OUTPATIENT Enter the total of lines 12 through 14.

INPATIENT DISCHARGES

Line 16; Total DA Inpatient Discharges for Patients without Insurance Enter the number of inpatient discharges for Disability Assistance patients who did not have insurance for the services delivered during your hospital's fiscal year.

Line 17: Total UC Inpatient Discharges for Patients Below 100% without Insurance

Enter the number of inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who did not have insurance for the service delivered, during your hospital’s fiscal year.

Line 18; Total UC Inpatient Discharges for Patients Above 100% without Insurance

Enter the number of inpatient discharges for patients with family incomes above the federal poverty income

guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative

Code, which did not have insurance for the services delivered, but were either unable or unwilling to pay for

some portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in

any other state cannot be included. NOY 29 2 raen

TN No. 10-006 Approval Date: IFS 02930-I (Rev. 4/2010) Stared effective Date: 07-0

Attachment 4.19 - A

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Line 19: Total UC Inpatient Discharges for Patients without Insurance Enter the total of lines 16 through 18.

OUTPATIENT VISITS

Line 20; Total DA Outpatient Visits for Patients without Insurance Enter the number of outpatient visits for Disability Assistance patients who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 21; Total UC Outpatient Visits for Patients Below 100% without Insurance

Enter the number of outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who did not have insurance for the service delivered, during your hospital's fiscal year.

Line 22; Total UC Outpatient Visits for Patients Above 100% without Insurance

Enter the number of outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which did not have insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 23: Total UC Outpatient Visits for Patients without Insurance Enter the total of lines 20 through 22.

Instructions for Column 3 COLUMN 3 Column 3 Includes the Medicaid inpatient and outpatient cost to charge ratios for your hospital.

Lines 8, 9, 10, and 31; Inpatient Cost to Charge Ratio

Divide the sum of the values in column 3, line 101, of Schedule D and column 3, line 101, of Schedule I by the sum of the values in column 2, line 101, of Schedule D and column 2, line 101, of Schedule I to calculate the inpatient cost to charge ratio.

; Outpatient Cost to Charge Ratio Divide the sum of the values in column 5, line 101, of Schedule D and column 5, line 101, of Schedule I by the sum of the values in column 4, line 101, of Schedule D and column 4, line 101, of Schedule I to calculate the outpatient cost to charge ratio.

Instructions for Columns 4 and 5

Calculation of Uncompensated Care Costs for Patients with Insurance

3; Column 4 Multiply the value in column 1 by the value in column 3 for each line and subtract the value in column 6.

Lines § through 15; Column 5 Multiply the value in column 2 by the value in column 3 for each line and subtract the value in column 7.

Instructions for Column 6

COLUMN 6 Information in Column 6 should include data for patients who have received uncompensated care

for some portion of their inpatient discharge or outpatient visit that was also covered by health insurance for

the services provided. hOY 29 2 TN No. 10-006 Approval Date:

JFS 02930-I (Rev. 4/2010) SUPERSEDES TN No. 09-027 Effective Date: 07-01-2010

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Page 23 of 52

INPATIENT RECEIPTS Receipts are to indude ALL payments received or reasonably expect to receive on account, from patients or their insurers.

Line 8; Total DA Receipts for Patients with Insurance — INPATIENT Enter the receipts for inpatient discharges by eligible Disability Assistance recipients, who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 9; Total UC Receipts for Patients Below 100% with Insurance — INPATIENT

Enter the receipts for inpatient discharges for patients not covered by Disability Assistance, with family Incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 10; Total UC Receipts for Patients Above 100% with Insurance — INPATIENT

Enter the receipts for inpatient discharges for patients with family incomes above the federal poverty income guidelines, and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 11: Total Inpatient Uncompensated Care Receipts for Patients with Insurance — INPATIENT Enter the total of tines 8 through 10.

OUTPATIENT RECEIPTS Receipts are to indude ALL payments received or reasonably expect to receive on account, from patients or their insurers.

Line 12: Total DA Receipts for Patients with Insurance — OUTPATIENT Enter the receipts for outpatient visits by eligible Disability Assistance recipients, who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 13; Total UC Receipts for Patients Below 100% with Insurance — OUTPATIENT

Enter the receipts for outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who had some form of insurance for the services delivered, during your . hospital's fiscal year.

Line 14: Total UC Receipts for Patients Above 100% with Insurance — OUTPATIENT

Enter the receipts for outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of The Ohio Administrative Code, who had some form of insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid In any other state can not be included of Schedule F.

Line 15; Total Uncompensated Care Receipts for Patients with Insurance — OUTPATIENT Enter the total of lines 12 through 14.

UNDUPLICATED INPATIENT DISCHARGES

Line 16: Total DA Unduplicated Inpatient Discharges for Patients with Insurance Enter the number of unduplicated inpatient discharges for Disability Assistance patients who also had some form of insurance for the services delivered during your hospital's fiscal year.

hUY 29 cui

TN No, 10-006 Approval Date:

JFS 02930-I (Rev. 4/2010) RN ers 02-027 Effective Date: 07-01-2010

Attachment 4.19 - A

Page 24 of 52

Line 17: Total UC Unduplicated Inpatient Discharges for Patients Below 100% with Insurance Enter the number of unduplicated inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3- 2-07.17 of the Ohio Administrative Code and who had some form of insurance for the service delivered, during your hospital's fiscal year.

Line 18; Total UC Unduplicated Inpatient Discharges for Patients Above 100% with Insurance Enter the number of unduplicated inpatient discharges for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of The Ohio Administrative Code, which had some form of insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 19: Total UC Unduplicated Inpatient Discharges for Patients with Insurance Enter the total of lines 16 through 18.

UNDUPLICATED OUTPATIENT VISITS

Line 20; Total DA Unduplicated Outpatient Visits for Patients with Insurance

Enter the number of unduplicated outpatient visits for Disability Assistance patients who also had some form of insurance for the services delivered, during your hospital's fiscal year.

Line 21; Total UC Unduplicated Outpatient Visits for Patients Below 100% with Insurance

Enter the number of unduplicated outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3- 2-07.17 of the Ohio Administrative Code and who had some form of insurance for the service delivered, during your hospital's fiscal year.

Line 22; Total UC Unduplicated Outpatient Visits for Patients Above 100% with Insurance

Enter the number of unduplicated outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which had some form of insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 23: Total UC Unduplicated Outpatient Visits for Patients with Insurance Enter the total of lines 20 through 22.

Instructions for Column 7

COLUMN 7 Information in Column 7 should include data for patients who have received uncompensated care and do not have any insurance for the services provided.

INPATIENT RECEIPTS

Receipts are to Indude ALL payments received or reasonably expect to receive on account, from patients or their insurers.

Line 8; Total DA Receipts for Patients without Insurance — INPATIENT Enter the receipts for inpatient discharges by eligible Disability Assistance recipients, who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 9; Total UC Receipts for Patients Below 100% without Insurance — INPATIENT Enter the receipts for inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2- 07.17 of the Ohio Administrative Code and who did not have insurance for the services delivered, during your hospital's fiscal year. + nuy 29 ea TN No. 10-006 Approval Date: JPS 02930-I (Rev. 4/2010) SUPERSEDES TN No. 09-027 Effective Date: 07-01-2010

Attachment 4.19-A

Page 25 of 52

Line 10; Total UC Receipts for Patients Above 100% without Insurance — INPATIENT

Enter the receipts for inpatient discharges for patients with family Incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohlo Administrative Code, who did not have insurance for the services delivered, but were either unable or unwilling to pay for a portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be induded on Schedule F.

Line 11; Total Uncompensated Care Receipts for Patients without Insurance — INPATIENT Enter the total of lines 8 through 10.

OUTPATIENT RECEIPTS Receipts are to include ALL payments received or reasonably expect to receive on account, from patients or their insurers.

Line 12; Total DA Receipts for Patients without Insurance — OUTPATIENT Enter the receipts for outpatient visits by eligible Disability Assistance recipients, who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 13; Total UC Receipts for Patients Below 100% without Insurance — OUTPATIENT

Enter the receipts for outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code and who did not have insurance for the services delivered, during your hospital’s fiscal year.

Line 14; Total UC Receipts for Patients Above 100% without Insurance — OUTPATIENT

Enter the receipts for outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, who did not have insurance for the services delivered, but were either unable or unwilling to pay for a Portion of the bill and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 15: Total Uncompensated Care Receipts for Patients without Insurance — OUTPATIENT Enter the total of lines 12 through 14.

UNDUPLICATED INPATIENT DISCHARGES

Line 16; Total DA Unduplicated Inpatient Discharges for Patients without Insurance Enter the number of unduplicated inpatient discharges for Disability Assistance patients who did not have insurance for the services delivered during your hospital's fiscal year.

Line 17; Total UC Unduplicated Inpatient Discharges for Patients Below 100% without Insurance Enter the number of unduplicated inpatient discharges for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3- 2-07.17 of the Ohio Administrative Code and who did not have insurance for the service delivered, during your hospital's fiscal year.

Line 18; Total UC Unduplicated Inpatient Discharges for Patients Above 100% without Insurance Enter the number of unduplicated inpatient discharges for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which did not have insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill and which were written off during your hospital's fiscal year. Redpients of Medicaid in any other state cannot be included.

Line 19; Total UC Unduplicated Inpatient Discharges for Patients without Insurance Enter the total of lines 16 through 18.

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Attachment 4.19 - A

Page 26 of 52 UNDUPLICATED OUTPATIENT VISITS

Line 20; Total DA Unduplicated Outpatient Visits for Patients without Insurance Enter the number of unduplicated outpatient visits for Disability Assistance patients who did not have insurance for the services delivered, during your hospital's fiscal year.

Line 21; Total UC Unduplicated Outpatient Visits for Patients Below 100% without Insurance Enter the number of unduplicated outpatient visits for patients not covered by Disability Assistance, with family incomes at or below the federal poverty income guidelines, who qualify for free care under rule 5101:3- 2-07.17 of the Ohio Administrative Code and who did not have insurance for the service delivered, during your hospital’s fiscal year.

Line 22: Total UC Unduplicated Outpatient Visits for Patients Above 100% without Insurance Enter the number of unduplicated outpatient visits for patients with family incomes above the federal poverty income guidelines and all others who do not qualify for free care under rule 5101:3-2-07.17 of the Ohio Administrative Code, which did not have insurance for the services delivered, but were either unable or unwilling to pay for some portion of the bill, and which were written off during your hospital's fiscal year. Recipients of Medicaid in any state can not be included on Schedule F.

Line 23; Total UC Unduplicated Outpatient Visits for Patients without Insurance Enter the total of lines 20 through 22.

I -STANDIN HIA ITAL INFORMA

LINE 24 Only free-standing psychiatric hospitals should complete this section.

Column 1; Payments from Insurance Enter payments received for psychiatric hospital inpatient services billed to and received from all sources other than the self-pay revenues in Column 2 and Ohio Medicaid payments reported on Schedule H.

Column 2; Payments from Self-Pay

Enter payments received for psychiatric hospital inpatient services billed to and received from either the person who received inpatient psychiatric services or the family of the person that received Inpatient psychiatric service.

Column 3: Charges for Charity Care

Enter the total charges for psychiatric hospital services provided to indigent patients. This indudes charges for services provided to individuals who do not possess health insurance for the services provided. However, this does not include bad debts, contractual allowances or uncompensated care costs rendered to patients with insurance where the full cost of service was not reimbursed because of per diem caps or coverage limitations.

Column 4; Government Cash Subsidies Received Enter the amount of cash subsidies received directly from state and local governments for psychiatric hospital inpatient services.

Column 5; Uncompensated Care Costs for Patients with Insurance Enter the psychiatric hospital inpatient costs for individuals that have insurance coverage for the service Provided, but full reimbursement was not received due to per diem caps or coverage limitations.

Column 6; Medicaid Days Provided to Medicaid Recipients Age 21 and Under Enter the total psychiatric hospital inpatient days provided to Ohio Medicaid recipients age 21 and under who were discharged during the hospital's fiscal year.

Wy 29 Lo TN No. 10-006 Approval Date: JFS 02930-I (Rev. 4/2010) TN NO 09-027 Effective Date: 07-01-2010

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Column 7: Medicaid Days Provided to Medicaid Recipients Age 22 to Age 64 Enter the total psychiatric hospital inpatient days provided to Ohio Medicaid recipients age 22 to age 64 who were discharged during the hospital's fiscal year.

Column 8; Medicaid Days Provided to Medicaid Recipients Age 65 and Over Enter the total psychiatric hospital inpatient days provided to Ohio Medicaid recipients age 65 and over who were discharged during the hospital's fiscal year.

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SCHEDULE G

TITLE XIX CAPITAL RELATED COST REIMBURSEMENT DRG EXEMPT HOSPITALS SHOULD NOT COMPLETE THIS SCHEDULE.

Column 1 Lines 25-34 and 37-97 - For each revenue center, transfer the total charges from Schedule B, column 4, fines 25 through 34, and 37 through 97.

Column 2 Lines 25-34 and 37-97 - For each revenue center, enter the "old" capital related cost from Worksheet B, Part II, column 25. The total of this column should match Worksheet B, Part II, column 25, line 95.

Column 3

Lines 25-34 and 37-97 - For each revenue center, enter the "new" capital related cost from Worksheet B, Part III, column 25. The total of this column should match Worksheet B, Part III, column 25, line 95. Column 4

Lines 25-34 and 37-97 - Enter the sum of columns 2 and 3.

Column 5

Lines 25-34 and 37-97 - Divide column 4 by column 1. Enter the result rounded to six decimal places. Column 6

Lines 25-34 and 37-97 - Enter the charge amounts from Schedule D, column 2.

Column 7

Lines 25-34 and 37-97 - For each revenue center, multiply column 6 by the corresponding ratio in column 5 and enter the result rounded to the nearest dollar.

Line 102 - Multiply the capital add-on rates in effect for the cost reporting period by the total number of XIX inpatient discharges on Schedule C-1, columns 2 and 3, line 40.

Columns 1-7 Line 35 - Enter the total of lines 25 through 34.

Line 98 - Enter the total of lines 37 through 97.

Line 101 - Enter the total of lines 35 and 98.

Column 7 Line 103 - Enter the result of line 102 less line 101.

hnuy 20

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SCHEDULE H

SETTLEMENT SUMMARY Section1 INPATIENT SERVICES

Line 1, columns 1-3 - Transfer amounts from Schedule D, column 3, line 101; Schedule D-1, column 9, line 101; and Schedule D, column 9, tine 101, into the appropriate column.

Line 2, columns 1-3 - Enter a

“ Do not indude payments received under the Hospital Care Assurance or UPL programs. * Indude in column 1;

Line 3, columns 1-3 - Enter the amount due from the program (based upon the reimbursement rate in effect when the service was rendered) for services rendered to eligible recipients during the reporting period for which reimbursement has not been received. See instructions for line 2 for the Payments to include in each column.

Line 4, columns 1-3 - Enter amounts received or receivable from other payers for services rendered to eligible program patients during the reporting period.

Line 5, columns 1 - Enter GROSS Inpatient UPL payments received for discharges occurring during this reporting period. Columns 2-4 reserved for JFS use.

Line 6, column 1 - Enter amount due Program/(Provider), using the opposite sign, from Schedule G, column 7, line 103. DRG-exempt and out-of-state hospitals, enter 0.

Line 7, columns 1-3 - Enter the sum of lines 2 through 6 (column 1 include line 5, column 4).

Line 8, columns 1-3 - Transfer amounts from Schedule D, column 2, line 101; Schedule D-1, column 8, line 101; and Schedule D, column 8, line 101, into the appropriate column.

In-State and DRG Exempt Hospitals move to Section II, line 10. DRG Out-of-State Hospitals complete line 9 before moving to Section II, line 10.

Line 9, column 1 - Enter the result of line 7 less line 8. If the result is negative, enter 0. NUE. CTI

Section IT OUTPATIENT SERVICES

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Page 30 of 52

Line 10, columns 1-2 - Transfer amounts from Schedule D, column 5, line 101 and Schedule D-1, column 11, line 101 into the appropriate columns.

Line 11, columns 1-2 - Enter the amount paid by th x

Patients during the reporting period. See instructions for section I, line 2. Do Not Include amounts paid by the programs for the following items:

1. Services billed under the At Risk Pregnancy program.

2. Amounts paid under the Hospital Care Assurance Program or UPL program.

3. Laboratory services with the exception of column 2 amounts which should indude Title V payments for Outpatient Radiology and Laboratory services.

Line 12, columns 1-2 - Enter the amount due from the Program (based upon the reimbursement rate in effect when the service was rendered) for services rendered to eligible recipients during the reporting period for which reimbursement has not been received. See instructions for section I, line 2.

Line 13, columns 1-2 - Enter amounts received or receivable from other Payers for services rendered to eligible program patients during the reporting period.

Line 14, columns 1 - Enter GROSS Outpatient UPL payments received for visits occurring during this reporting period. Column 2 - LEAVE BLANK - reserved for JFS use.

Line 15, columns 1-2 - Enter the sum of lines 10 through 14 (column 1 include line 14, column 4).

Line 16, columns 1-2 - Enter amounts from Schedule D, column 4, line 101 and Schedule D-1, column 10, line 101.

In-State and DRG Exempt Hospitals move to Section III, line 20. DRG Out-of-State Hospitals complete lines 17 thru 19 before moving to Section IV, line 28.

Line 17, column 1 - Subtract line 15 from line 10.

Line 18 column 1 - Subtract line 16 from line 10. If the result is negative enter -0-,

Line 19, column 1 - Subtract line 17 from line 18.

CONTINUE TO SECTION IV, LINE 28

Section III SETTLEMENT TEST

THIS SECTION IS ONLY TO BE COMPLETED BY ALL DRG Exempt, and In-State DRG Hospitals

Line 20, columns 1-3 - Combine amounts from each column of Schedule H, Section I, line 1, and Section II, line 10 into the appropriate column.

Line 21, columns 1-3 - Combine amounts from each column of Schedule H, Section I, line 7, and Section I, line 15 into the appropriate column.

Line 22, columns 1-3 - Combine amounts from each column of Schedule H, Section I, line 8, and Section II, line 16 into the appropriate column.

Line 23, column 1 - Enter -0-. DRG-exempt hospitals, subtract line 21 from line 20.

Line 23, columns 2 and 3 - Subtract line 21 from line 20. HOY 25 coy TN No. 10-006 Approval Date:

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Attachment 4.19 - A

Page 31 of 52

Line 24, column 1 - Enter -0-. DRG-exempt hospitals, subtract line 22 from line 20. If the result is negative, enter -0-.

Line 24, columns 2 and 3 - Subtract line 22 from line 20. If the result is negative, enter -0-,

Line 25, column 1 - Enter the result of line 21 less line 22. If the result is negative, enter 0. DRG-exempt hospitals, subtract line 23 from line 24.

Line 25, columns 2 and 3 - Subtract line 23 from line 24.

SectionIV PROGRAM(S) SUMMARY

Line 26, columns 1-3 — In-State DRG and DRG Exempt hospitals enter the amounts from Schedule H, Section III, line 25, Out-of-State DRG hospitals enter combined settlement amounts from Schedule H, Section I, line 9 and Schedule H, Section II, line 19.

Line 27, column 1 - Enter the amount from Schedule G, column 7, line 103. DRG-exempt hospitals, enter 0.

Line 29, columns 1-3 - Enter the sum of lines 26 and 27.

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SCHEDULE I

TITLE XIX HMO COST CALCULATIONS OUT-OF-STATE HOSPITALS SHOULD NOT COMPLETE THIS SCHEDULE.

Include charges for the following;

" Patients whose primary coverage was an Ohio Medicaid Managed Care Plan and a payment was received directly from the Medicaid Managed Care Pian.

" Patients whose Ohio Medicaid Managed Care Plan coverage was secondary to other insurance, (e.g. Blue Cross, Aetna) and a payment was received from both the Primary Insurer and the Medicaid Managed Care Plan.

* Patients whose Ohio Medicaid Managed Care Plan coverage was secondary to other insurance, (e.g. Blue Cross, Aetna, Railroad, etc.) and a payment was received from only the Primary Insurer and the daim was reported as “paid” on the Ohio Medicaid Managed Care Pian remittance advice.

* Patients for any of the above situations for which you have submitted a daim and reasonably expect to receive a payment from the payer.

Do Not Include charges for patients enrolled in Medicare or a Medicare Advantage Plan as Ohio Medicaid only pays cost sharing (coinsurance and/or deductible) for these claims.

SECTION I

Column 1 Lines 25-33 and 37-97 - Enter the ratio from Schedule 8, column 5 for each revenue center on the corresponding lines.

Column 2 Lines 25-33 and 37-97 - Enter the charges for Title XIX covered inpatient services rendered during the reporting period.

Column 3 Lines 25-33 and 37-97 - Multiply the charges in column 2 by the corresponding ratio in column 1. Enter the result rounded to the nearest dollar.

Column 4 Lines 25-33, 37-40, and 45-97 - Enter the charges for Title XIX covered outpatient services. Do not include charges for Outpatient Laboratory Services.

Column Lines 25-33, 37-40, and 45-97 - Multiply the charges in column 4 by the corresponding ratio in column 1. Enter the result rounded to the nearest dollar.

Column 6 - This column is reserved.

Column 7 Lines 25-33 and 37-97 - Enter the ratio from Schedule G, column 5, for each revenue center on the corresponding line.

Column & . Lines 25-33 and 37-97 - Multiply the charges in column 2 by the corresponding ratio in column 7. Enter the result rounded to the nearest dollar.

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Page 33 of 52

Line 102 - Multiply the capital add-on rates in effect for the cost reporting period by the total number of Medicaid HMO inpatient discharges on Schedule C-1, columns 7 and 8, line 40.

Columns 2-8 Line 35 - Enter the total of lines 25 through 33.

Line 98 - Enter the total of Lines 37 through 97.

Line 101 - Enter the total of lines 35 and 98.

SECTION IT

HMO inpatient encounters should be counted as the number of HMO Inpatient discharges and the number of total inpatient days associated with the reported discharges, for which a hospital was paid and/or expects to receive payment.

HMO Outpatient encounters should be counted as the number of HMO Outpatient claims for which a hospital was paid and/or expects to receive payment. Series accounts/cycle bills should be counted as 1 visit per claim (not the number of dates of service on that claim).

Line 103, column 2 - Enter the total XIX inpatient HMO days Schedule C-2, Column 2, Line 35.

Line 103, column 4 - Enter the total XIX outpatient HMO visits.

Line 104, column 2 — Enter the total facility inpatient HMO days.

Line 104, column 4 - Enter the total facility outpatient HMO visits.

Line 105, column 2 - Enter the total XIX inpatient HMO discharges Schedule C-1, column 7, line 40 plus Schedule C-1, column 8, line 40.

Line 106, column 2 - Enter the total facility inpatient HMO discharges.

Line 107 Report all amounts received or receivable as payment for the charges reported in Section I. Include all amounts received or receivable from Ohio Medicaid Managed Care Plans directly as well as those amount received or receivable from other payers (Blue Cross, Aetna, Railroad, etc) for Ohio Medicaid Managed Care enrollees.

Line 107, column 2 - Enter the total XIX inpatient HMO payments,

Line 107, column 4 - Enter the total XIX outpatient HMO payments.

: . , TN No. 10-006 Approval Date: JFS 02930-I (Rev. 4/2010) - Wie goa effective Date: 07

Ohio Department of Job and Family Services HOSPITAL COST REPORT STATE FISCAL YEAR 2010

CERTIFICATION BY OFFICER OF HOSPITAL

In accordance with current Medicaid regulations (42CFR, 455.18, 455.19) all cost reports must ccntain the following:

This is to certify that the foregoing information is true, accurate, and complete.

T understand that payment of this Medicaid claim will be from Federal and State funds, and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws.

I hereby certify that I have read the above statement and that I have examined the accompanying cost report supporting schedules prepared for:

Provider Name Medicaid Number [National Provider Identifier ‘Street Address Federal ID Number (City, State and Zip Code Medicare Provider Number(s)

for the cost reporting period beginning and ending and that to the best of

my knowledge and belief, it is a true, correct, and complete statement prepared from the books and records of the provider(s) in accordance with applicable instructions and regulations including independent certification of Schedule F, and the accuracy of the OBRA Suney, except as noted.

Signature of Officer or Administrator of Provider(s) [Date of Signature Print or Type Name Tide: Name of Individual Report Was Prepared By Tite

Name of Person to Contact Regarding Report Tite

[Telephone Number (Include Area Code & Extension (if applicable)

{

ey. TN No. 10-006 Approval Date: SUPERSEDES

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JFS 02930 (Rev. 4/2010)

Attachment 4.19 - A Page 35 of 52

OBRA SURVEY

Medicaid programs must, on an annual basis, determine whether hospitals which receive disproportionate share Payments under Medicaid meet certain federally-mandated requirements. For instance, urban non-chikdren's hospitals which receive disproportionate share payments and which offer non-emergency obstetrical services must have at least two obstetricians on staff who have agreed to service Medicaid patients, Rural hospitals which offer Non-emergency obstetrical services must have at least two physicians (not necessarily obstetricians) who have agreed to provide obstetrical services to Medicaid recipients in order to receive Medicaid disproportionate share payments. A related requirement is that states must Provide disproportionate share payments to hospitals with a low-income utilization rate that exceeds 25 percent.

Complete Section A and Section 8 for your facility for this cost reporting period.

Answer: Section A YES| NO | N/A 1 Does your hospital predominantly serve patients less than 18 years of age? (If answer to this question is olo Yes, please proceed to Section B.) 2 As of December 22, 1987, did your hospital offer non-emergency obstetric services to the general ololo Population? (If answer to this question is No, please proceed to Section B, if Yes answer question 3.) 3 Does your hospital currently offer Non-emergency obstetric services to the general population? (If answer to| Ololo this question is Yes, please proceed to Section B.) 4 Answer the one question below appropriate to your hospital. If your hospital is deemed a rural hospital for purposes of

Medicare reimbursement, answer question (a). If your hospital is an urban hospital for purposes of Medicare reimbursement, answer question (b).

a Rural: Does your hospital have at least two physicians (may or may not be Obstetricians) with staff Privileges who have agreed to provide non-emergency obstetric services to Medicaid recipients? If, O| O [O you responded No, please explain below.

b Urban: Does your hospital have at least two obstetricians with staff privileges who have agreed to Provide non-emergency obstetric services to Medicaid recipients? If you responded No, please OJ O}O explain below.

Section B The following section should be completed by hospitals to determine if a low-income utilization rate (as described below) which exceeds 25% exists.

“Low-income utilization rate" means, according to federal law, the sum of (1) and (2) below: (1) the fraction, expressed as a percentage:

(a) the numerator of which is the sum for a period of Medicaid (Ohio only) revenues (payments including HMO payments for patient services plus the amount of cash subsidies (induding HCAP and UPL payments) for patient services received directly from state and local governments.

(b) the denominator of which is the total patient services revenue — including such cash subsidies -- for the period.

(2) the fraction, expressed as a percentage:

(a) the numerator of which is the total (gross) hospital inpatient charges in a period attributable to charity care (not including contractual allowances and discounts and bad debts) less the portion of any subsidies received in the Period from state and local governments reasonably attributed to inpatient hospital services.

(b) the denominator of which is total (gross) hospital inpatient charges in the period. Provide the following information from your financial records:

Fraction 1 Medicaid Revenues: Plus: Government Cash Subsidies: | Fraction (1) Total patient revenues including cash subsidies: {_ ] [ ]

Fraction 2 Total hospital inpatient charges for charity care (not including allowances, discounts and bad debts); Less: Government cash subsidies: ] Fraction (2)

Total inpatient charges: [ ] { ]

Sum of Fraction (1) and (2) expressed as a percent:|______

TN No. 10-006 Approval Date: SUPERSEDES JFS 02980 (Rev. 4/2010) TN No, 09-027 Effective Date: 07-01-2010

Attachment 4.19 - A Page 36 of 52

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES

SFY 2010 INPATIENT BILLING CODE ALLOCATION UB-92 Revenue Center Codes 25. Adult & Pediatric 001, 100, 110-113, 116, 117, 119-123, 126, 127, 129-133, 136, 137, 139, 150-153, 156, 157, 159, 160, 164, 169, 206, 214, 230, 232, 239, 240-243, 249 25a. Distinct Part Psychiatric 114, 124, 134, 154 25b. Distinct Part Rehabilitation 118, 128, 138, 158 26. Intensive Care 200, 201-204, 208, 209, 233 27. Coronary Care 210-213, 219, 234 28. Burn Unit 207 29. Surgical Intensive Care 204 30. Other Special Care * 31. Nursery Intensive Care 174 33. Nursery 170-173, 179, 231 37. Operating Room 360-362, 367, 369 37a. Ambulatory Surgery 490, 499 37b. Cast Room 700, 709 37c. Treatment or Observation Room 760-762, 769 38. Recovery Room 710, 719 39. Delivery & Labor Room 720-724, 729 40. Anesthesiology 370-372, 379 41. Radiology - Diagnostic 320-324, 329, 400, 401, 403, 409, 790, 799, 920 41a. CAT Scan 350-352, 359 41b. Ultrasound 402 41c. PET Scan 404 41d. MRI 610-612, 614-616, 618, 619 42. Radiology - Therapeutic 330-333, 335, 339 43. Radioisotope / Nuclear Medicine 340-342, 349 44. Laboratory 300-302, 304-307, 309-312, 314, 319, 921, 923-925, 929 44a. Oncology 280, 289 46. Whole Blood & Blood Components 380-387, 389 47. Blood Processing, Storing & Transfusion [390, 391, 399 48. Intravenous Therapy 260-264, 269 49. Respiratory Therapy 410, 412, 413, 419 49a. Pulmonary Function 460, 469 50. Physical Therapy 420-424, 429, 530, 531, 539, 922, 940, 942, 949, 952 50a. Cardiac Rehab 943 51. Occupational Therapy 430-434, 439 52. Speech & Hearing Services 440-444, 449 52a. Audiology 470-472, 479 53. Electrocardiology 480, 482, 483, 489, 730-732, 739 53a. Cardiac Catheterization 481 54. Electroencephalography 740, 749 55. Medical Supplies 270-272, 274-276, 278, 279, 291, 621-623 56. Pharmacy 250-252, 254, 255, 257-259, 634-637 57. Renal Dialysis 800-804, 809, 880-881, 889 58. Organ Acquisition 810-812, 819 59. Psychiatric/Psychological Services 900, 909, 910, 914-916, 918-919 60. Cinic 510-517, 519, 770, 771, 779 61. Emergency 450-452, 456, 459 62. Observation Beds * 69. Gastrointestinal Services 750, 759 70. * *

Please refer to OAC 5101:3-2-02 for a list of inpatient and outpatient covered services.

*Billing codes should be allocated into revenue centers as indicated above. Any deviation from the above must be designated

above to indicate where the billing codes were allocated, and why they were allocated differently than requested.

*Do not indude observation bed costs and charges reported on line 62 of the JFS 2930 and HCFA 2552-96 in revenue center 37b.

*If one revenue center code is applicable to more than one revenue center, please show which revenue centers it was allocated to on the following page

* Please list the revenue center codes allocated to these revenue centers.

HOV ZY TN No. 10-006 Approval Date:

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IPS 02930 (Rev. 4/2010)

Attachment 4.19- A Page 37 of 52

OHIO DEPARTMENT OF 308 AND FAMILY SERVICES

SFY 2010 OUTPATIENT BILLING CODE ALLOCATION

UB-92 Revenue Center Codes

25. Aduit & Pediatric

001, 110-113, 116, 117, 119,-123, 126, 127, 125-133, 136, 137, 139, 150-153, 156, 157, 159, 160, 164, 169

25a, Distinct Part Psychiatric

114, 124, 134, 154

25b. Distinct Part Rehabilitation

118, 128, 138, 158

26. Intensive Care

27. Coronary Care

28, Burn Unit

29. Surgical Intensive Care

30. Other Special Care

31. Nursery Intensive Care

33. Nursery 170, 171, 179

37. Operating Room 360, 361, 369

37a. Ambulatory Surgery 490, 499

37b. Cast Room 700, 709

37¢. Treatment or Observation Room 760-762, 769

38. Recovery Room 710, 719

39. Delivery & Labor Room 720-724, 729

40. Anesthesiology 370-372, 379

(41. Radiology - Diagnostic 320-324, 329, 400, 401, 403, 409, 790, 799, 920 41a. CAT Scan 350-352, 359

41b. Utrasound 402

41c. PET Scan 404

4id. MRI 610-612, 614-616, 618, 619

42. Radiology - Therapeutic 330-333, 335, 339

43. Radioisotope / Nuclear Medicine 340-342, 349

44, Laboratory 300-302, 304-307, 309-312, 314, 319, 921, 923-925, 929 44a. Oncology 280, 289

46. Whole Blood & Blood Components 380-387, 389

47. Blood Processing, Storing & Transfusion [390, 391, 399

48. Intravenous Therapy 260-264, 269

49. Respiratory Therapy 410, 412, 413, 419

49a. Pulmonary Function 460, 469

50. Physical Therapy 420-424, 429, 530, 531, 539, 922, 940, 942, 949, 952 50a. Cardiac Rehab 943

51. Occupational Therapy 430-434, 439

52. Speech & Hearing Services 440-444, 449

‘52a. Audiology 470-472, 479

53. Blectrocardiology 480, 482, 483, 489, 730-732, 739

53a. Cardiac Catheterization 481

54. Electroencephalography 740, 749

55. Medical Supplies

270-272, 276, 278, 279, 621-623

56. 250-252, 254, 255, 258, 259, 634-637 57. Renal Dialysis 820, 821, 829-831, 839-841, 849-851, 859, 880, 881, 889 58. Organ Acquisition

59. Psychiatric/Psychological Services

900, 909-911, 914-916, 918, 919, 944, 945

60. Clinic

510-517, 519, 770, 771, 779

61. Emergency

450-452, 456, 459

62. Observation Beds

¥

69. Gastrointestinal Services

70.

750, 759 *

71,

72.

=

Please refer to OAC 5101:3-2-02 for a list of inpatient and outpatient covered services.

Follow the same procedures as outlined on the Inpatient Billing Code Allocation Sheet

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