Ohio has not yet distributed any of the funds for long-term facilities and services that its General Assembly appropriated in House Bill 169. As of Monday, January 18, the Ohio Department of Medicaid had not filed for the necessary federal approvals with the Centers for Medicare and Medicaid Services, attributing the holdup to a change in the methodology for distributing the $300 million designated for skilled nursing facilities, which was to be based on numbers of certified beds. The revised formula has 75 percent of the payout based on Medicaid days from 2020 cost reports. The remaining 25 percent is to be distributed according to “quality points” from the July 1, 2021, rate-setting, without excluding facilities ranking lower than the 25th percentile.

The Ohio Senate and House have passed legislation to provide in excess of $350 million for the State’s long-term care (LTC) facilities and services. The bill, sponsored by State Reps. Al Cutrona (R) and D.J. Swearingen (R), restricts payments to pay, bonuses, and incentives to recruit and retain the direct-care workforce. The monies cannot be used to pay other operating costs and expenses.

In addition to $300 million for nursing homes, the bill sets aside $23 million for hospice services and $33 million for assisted living facilities, which have also experienced staff challenges during the COVID-19 pandemic. The money is derived from federal funds allocated to Ohio, and according to the legislation, must be distributed by the end of 2022. But the State has not yet announced when funds will be distributed, and apparently is awaiting federal approval.

The Ohio Department of Medicaid (ODM) will be responsible for distributing the money. ODM plans to allocate the money based on each skilled nursing facility’s (SNF) certified bed count as of December 31, 2021. Current expectations are that $3,500 will be allocated for each “skilled” bed. ODM has confirmed that $500 will be allocated for each Assisted Living bed, matching the request of the Ohio Health Care Association.

According to the U.S. Bureau of Labor Statistics, about 420,000 skilled employees have left the profession over the past two years. Ohio operators have been offering incentives for sign-on bonuses and educational costs, but the efforts have failed to make a dent in employment shortfalls. It appears the State is hoping that money will convince the workers to stay, maybe even come back. But studies show that especially younger workers are more concerned about COVID-related health issues and free time than bonuses.

Can Ohio LTC facilities use the money for costs like maintenance, dietary and janitorial staff? Not according to the letter of the law, which limits payments to those directly caring for patients. Facilities could benefit by using the funds to address a variety of expenses. With elective surgeries reduced and a general unease of the public, the number of private therapy patients, who generate higher revenues, has fallen, as has the number of Medicare patients as the concentration of Medicaid patients grows, driving down per patient revenues and creating losses for providers. The State would be wise to allow long-term care facilities to use the funds to pay a wider range of expenses so they can remain open and providing care.

Following the announcement Thursday that healthcare providers in 24 states had been added to the federal vaccine mandate roster, the Centers for Medicare & Medicaid Services (CMS) announced Friday that those workers must be fully vaccinated by March 15. The 24 states joined 25 others, Washington, D.C, and territories, whose workers must have at least one COVID-19 shot by January 27, and be fully vaccinated by February 28. The mandates are based on guidance issued December 28 and follow Thursday’s U.S. Supreme Court ruling removing an earlier injunction to the mandate issued by a lower federal court.

The sweeping mandate applies to workers at hospitals and other healthcare facilities, including nursing homes and other long-term care facilities, that participate in Medicare and Medicaid programs. “Regardless of clinical responsibility or resident contact, the policies and procedures must apply to … individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.”

The states included in the compliance memo are Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Utah, West Virginia, and Wyoming. The mandate now extends to all U.S. states except Texas, where a preliminary injunction still applies.

The CMS memo warned that, “Facilities that do not meet these parameters could be subject to additional enforcement actions depending on the severity of the deficiency and the type of facility … (including) plans of correction, civil monetary penalties, denial of payment, termination, etc.”

Additional Distribution
The Department of Health and Human Services (HHS) announced the distribution of an additional $5 billion from the Provider Relief Fund (PRF) to Medicare-certified long-term care facilities and state veterans’ homes (nursing homes). The intended purpose of the funding is to improve the nursing homes’ response to COVID-19 and enhance the skillset of front-line workers. To emphasize this purpose, recipient nursing homes must participate in CMS’ Nursing Home COVID-19 Training which will focus on infection control and best practices. Funding received can be utilized to address critical needs such as hiring additional personnel, implementing infection control programs, increasing COVID-19 testing, and providing additional services (i.e. technology for residents to communicate with their families who are unable to visit).

Reporting Guidance
HHS recently issued a reporting timeline for providers who received more than $10,000, cumulatively, from the CARES Act/Provider Relief Fund distributions.

Applicable CARES Act/Provider Relief Fund distributions include:

• Medicare Distribution
• Additional Medicare Distribution
• Medicaid, Dental & CHIP Distribution

• High Impact Area Distribution
• Rural Distribution
• Skilled Nursing Facilities Distribution
• Indian Health Service Distribution
• Safety Net Hospital Distribution

Beginning October 1, 2020, the reporting system will be available to providers to submit and fulfill their reporting obligation. Providers have until February 15, 2021 to report their expenditures through December 31, 2020. Alternatively, providers with unexpended funds through December 31, 2020 have until July 31, 2021 to submit an additional final report.

Detailed instructions and a data collection template are scheduled to be released from HHS by August 17, 2020. The reports are expected to allow providers to demonstrate compliance with the Terms & Conditions of the PRF payments received. The Health Resources and Services Administration intends to provide Question and Answer webinars in advance of the submission deadline; however, the dates of these webinars have not yet been released.

Audit Requirements
In addition to the aforementioned reporting requirement, HHS indicated that providers (for-profit and not-for-profit) that expend $750,000 or more of PRF funds during their fiscal year will be subject to an audit in accordance with Government Auditing Standards. Providers which follow calendar-year reporting should be particularly cognizant of this audit requirement threshold when determining which costs are expended to each period.

What This Means for Providers Now
Providers receiving HHS should begin planning for these reporting requirements. Planning includes gathering the necessary documentation for eligible costs incurred as well as strategically identifying when costs are reported whereas to not trigger an audit, or worse, two audits.

If you have any questions about the above information or would like to further discuss planning opportunities, HBK’s Healthcare Solutions team is here to help. Feel free to contact us at (330) 758-8613 or email me directly at kcrouthamel@hbkcpa.com.