5101:1-41-02 Breast and cervical cancer project (BCCP) medicaid: definitions.

(A) "Centers for Disease Control and Prevention (CDC) Title XV grantee" means an entity receiving funds under a cooperative agreement with CDC to support activities related to the national breast and cervical cancer early detection program.

(B) "The National Breast and Cervical Cancer Early Detection Program (NBCCEDP)" means the program of the centers for disease control and prevention (CDC) established under Title XV of the Public Health Service Act.

(C) "The Ohio Department of Health (ODH) Breast and Cervical Cancer Project (BCCP)" means the national breast and cervical cancer early detection program (NBCCEDP) funded by the centers for disease control and prevention (CDC) and administered by the Ohio department of health (ODH).

(1) "ODH BCCP enrollee" means an individual determined by the ODH BCCP, or its designated local agencies or subgrantees, to meet the eligibility requirements (e.g., age and income) for participation in the ODH BCCP.

(2) "ODH BCCP designated local agency or subgrantee" means an entity which has received a grant from ODH to implement specified activities of the ODH BCCP.

(3) "ODH BCCP breast and cervical cancer screening provider" means an entity which has entered into written agreement with the ODH BCCP to provide specified breast and cervical cancer screening and diagnostic services for ODH BCCP enrollees.

(D) "Breast and Cervical Cancer Project (BCCP) Medicaid" means the category of medicaid for qualified individuals in need of treatment for breast or cervical cancer, including pre-cancerous conditions and early stage cancer. BCCP medicaid is administered by the Ohio department of job and family services (ODJFS) in coordination with the ODH.

(E) "Screened for breast or cervical cancer under the centers for disease control and prevention's (CDC) national breast and cervical cancer early detection program (NBCCEDP)" means that a breast or cervical cancer screening was provided all or in part by CDC Title XV funds.

(1) For the purposes of BCCP medicaid, breast or cervical cancer screening includes diagnostic test(s) following a breast or cervical cancer screen.

(2) For the purposes of BCCP medicaid, case management services provided by a CDC Title XV grantee are not considered breast or cervical cancer screening.

(F) For the purposes of BCCP medicaid, "breast or cervical cancer diagnosis" means that a treating health professional has made a general determination that breast or cervical cancer(s) or pre-cancerous condition(s) exists. For the purposes of BCCP medicaid, breast or cervical cancer diagnosis does not require the determination of the specific stage or grade of cancer or pre-cancerous conditions.

(1) "Breast or cervical cancer diagnosis" includes metastasized cancer known or presumed by a treating health professional as a complication of breast or cervical cancer.

(2) "Pre-cancerous" means a condition, which, if left untreated is known or presumed by a treating health professional to develop into cancer.

(3) "Date of diagnosis" is the date of the screening or diagnostic service which the treating health professional utilized to determine the individual's breast or cervical cancer diagnosis.

(G) "Treatment" means the provision of medical services to control, minimize, or eliminate cancer or pre-cancerous cells of the breast or cervix. "Treatment" includes the provision of hormonal therapies to prevent recurrence of cancer following breast cancer surgery, radiation, and/or chemotherapy. Monitoring services alone (e.g., Papanicolaou smears, pelvic examinations, clinical breast examinations, mammograms) for recurrence or new primary cancers are not considered treatment.

(1) "Needs treatment" means that according to a written certification by the individual's treating health professional, which is documented by the ODH BCCP, a breast or cervical cancer screening indicates that the woman is in need of treatment for breast or cervical cancer. Woman who are determined to require only monitoring services (e.g., Papanicolaou smears, pelvic examinations, clinical breast examinations, mammograms) are not considered to need treatment.

(2) "Treating health professional" means an individual licensed to provide breast or cervical cancer diagnosis and/or treatment services.

(3) "No longer receives treatment for breast or cervical cancer" means

(a) The individual's course of treatment of breast or cervical cancer is completed, or

(b) The individual chooses to delay or decline available treatment options.

(4) "Treatment period" means the period of time, according to a written certification by the individual#s treating health professional, needed for the completion of treatment of the individual's breast or cervical cancer or pre-cancerous condition. A treatment period lasting more than twelve months from initial eligibility requires both a review of continuing medicaid eligibility and verification of need for continued treatment.

(H) "Uninsured" means not having creditable coverage for health care services.

(1) For the purposes of determining eligibility under BCCP medicaid, the following are considered creditable coverage unless one of the exceptions in paragraph (H)(2) of this rule is applicable:

(a) Health insurance benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract;

(b) Health maintenance organization contract offered by a health insurance issuer;

(c) Medicare, parts A and B; and,

(d) Medicaid.

(2) For the purposes of determining eligibility under BCCP medicaid, creditable coverage does not include:

(a) Limited scope coverage such as those which only cover dental, vision, or long term care;

(b) Coverage for only a specified disease or illness;

(c) Coverage which excludes treatment for breast or cervical cancer, including situations whereby a period of exclusion has been applied, such as for a pre-existing condition or the individual has exhausted the health insurance plan's covered benefits;

(d) Delayed spenddown eligibility under the spenddown process provided in rule 5110:1-39-10 of the Administrative Code;

(e) Disability assistance (DA) Medical coverage, including, for example, coverage obtained by an individual who is medication dependent, as provided in rule 5101:1-5-20 of the Administrative Code; or

(f) Medicare part A only or medicare part B only.

Eff 7-1-02
Rule promulgated under: RC 111.15
Rule authorized by: RC 5111.0110
Rule amplifies: RC 5111.0110
R.C. 119.032 review dates: 07/01/2007