Chapter 5160-56 Medicaid Hospice Program

5160-56-01 Hospice services: definitions.

Hospice care is end-of-life care provided by health professionals and volunteers. Hospice care is an approach to caring for terminally ill consumers that stresses palliative care as opposed to curative care. Hospice care incorporates an interdisciplinary team approach to meet the consumer's physical, psychological, social, and spiritual needs, as well as the psychosocial needs of the consumer's family.

Paragraphs (A) to (GG) of this rule define terms used in the rules governing the medicaid hospice program as contained in Chapter 5101:3-56 of the Administrative Code.

(A) "Advance directive" means a written instruction, such as a living will, a declaration, as defined in Chapter 2133. of the Revised Code, or a durable power of attorney for health care, as defined in Chapter 1337. of the Revised Code, which is recognized under state law and relates to the provisions of health care when the individual is incapacitated.

(B) "Advance practice nurse" means a registered nurse authorized to practice as a certified nurse specialist, certified registered nurse anesthetist, certified nurse midwife or certified nurse practitioner in accordance with section 4723.43 of the Revised Code.

(C) "Attending provider" is:

(1) A doctor of medicine or osteopathy legally authorized to practice medicine and surgery as authorized under Chapter 4731. of the Revised Code in which he or she performs that function or action. This provider is identified by the consumer or the representative, at the time he or she elects the hospice benefit, as having the most significant role in the determination and delivery of the consumer's medical care; or

(2) An advanced practice nurse who meets the training, education, and experience requirements in accordance with section 4723.43 of the Revised Code. Advanced practice nurses are prohibited from certifying or recertifying a terminal diagnosis. This provider is identified by the consumer or the representative, at the time he or she elects the hospice benefit, as having the most significant role in the determination and delivery of the consumer's medical care.

(D) "Bereavement counseling" means counseling services provided to the consumer's family or caregivers after the consumer's death.

(E) "Core hospice services" are nursing care, medical social services, counseling services, and physician services that must routinely be provided directly by the employees of the hospice.

(F) "Counseling services" are services provided for the purpose of counseling or training the caregiver and helping the beneficiary and the family members and/or caregiver with adjustment to the approaching death.

(G) "Dietary counseling" means intervention and education regarding appropriate nutritional intake that is provided to the consumer and/or the consumer's family by a qualified professional including, but not limited to, a registered nurse, a dietitian and/or a physician.

(H) "Dietitian" means a person licensed to practice dietetics who meets the criteria set forth in Chapter 4759. of the Revised Code.

(I) "Election period" is a period for which the consumer is enrolled in the hospice benefit. The election period is subject to the conditions set forth is this chapter and are listed below in sequential order:

(1) An initial ninety-day period (limited to one during the consumer's lifetime).

(2) A second subsequent ninety-day period (limited to one during the consumer's lifetime).

(3) An unlimited number of subsequent sixty-day periods.

(J) "Home and community based services (HCBS) waivers" are operated in accordance with Section 1915 (c) of the Social Security Act (the Act). The HCBS waiver programs include those waivers operated by the Ohio department of job and family services (ODJFS), the Ohio department of aging (ODA), and the Ohio department of mental retardation and developmental disabilities (ODMRDD).

(K) "Home health aide" means a person who meets the training, aptitude and skill requirements to provide home care services for the hospice consumer and his or her family in accordance with rule 3701-19-16 of the Administrative Code.

(L) "Hospice" is a public agency or private organization or a subdivision of either that is licensed in the state of Ohio and is primarily engaged in providing care to terminally ill consumers.

(M) "Interdisciplinary group (IDG)" is composed of individuals who provide or supervise the care and the services offered by the hospice. The group must include a physician, a registered nurse, a social worker, and a spiritual or another counselor who are employees of the hospice in accordance with the 42 CFR 418.68 (November 1, 1983).

(N) "Intermediate care facility for the mentally retarded" (ICF-MR) means an intermediate care facility for the mentally retarded certified as in compliance with applicable standards for the medical assistance program by the director of health in accordance with Title XIX of the Social Security Act.

(O) "Inpatient facility" means a facility that either is operated by or under contract with a hospice for the purpose of providing inpatient care to the consumer.

(P) "Licensed occupational therapist" means a person holding a valid license under Chapter 4755. of the Revised Code as an occupational therapist.

(Q) "Licensed occupational therapy assistant" means a person holding a valid license under Chapter 4755. of the Revised Code as an occupational therapy assistant (OTA).

(R) "Licensed physical therapist" means a person holding a valid license under Chapter 4755. of the Revised Code as a physical therapist.

(S) "Licensed physical therapy assistant" means a person holding a valid license under Chapter 4755. of the Revised Code as a physical therapist assistant (PTA).

(T) "Licensed speech-language pathologist" means a person holding a valid license under Chapter 4753. of the Revised Code as a speech-language pathologist and who is eligible for or meets the educational requirements for a certificate of clinical competence in speech language pathology granted by the "American Speech-Language-Hearing Association."

(U) "Licensed speech-language pathology aide" means a person holding a valid license under Chapter 4753. of the Revised Code as a speech-language pathology aide.

(V) "Medical director" must be a hospice employee or contracted employee who is a doctor of medicine or osteopathy who assumes overall responsibility for the medical component of the hospice's patient care program.

(W) "Medicare" is the federally financed medical assistance program determined under Title XVIII of the Social Security Act.

(X) "Non-core hospice services" are hospice services that are the responsibility of the hospice to ensure are provided directly to the consumer by hospice employees or under a contractual arrangement made by the hospice.

(Y) "Nursing facility" (NF) means a facility, or a distinct part of a facility, that is certified as a nursing facility by the director of health in accordance with Title XIX of the Social Security Act, and is not an intermediate care facility for the mentally retarded (ICF-MR).

(Z) "Nursing services" are services that require the skills of a registered nurse, or a licensed practical nurse under the supervision of a registered nurse. Services provided by an advanced practice nurse who is not the patient's attending provider or are not provided by a physician in the absence of an advanced practice nurse are included under nursing services.

(AA) "ODJFS" means Ohio department of job and family services.

(BB) "Palliative care" seeks to prevent or relieve the symptoms produced by a life-threatening medical condition or its treatment, to help patients with such conditions and their families lives as normally as possible, and to provide them with timely and accurate information and support in decision making.

(CC) "Physician" means a person who is authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery.

(DD) "Physician services" means services provided by a person as defined in rules 5101:3-4-01 to 5101:3-4-05 of the Administrative Code.

(EE) "Registered nurse" means a person licensed to practice nursing as a registered nurse who meets the criteria set forth in Chapter 4723. of the Revised Code.

(FF) "Representative" means an adult, eighteen years or older, who has been authorized under Ohio law to make health care decisions on behalf of the consumer who is mentally or physically incapacitated, or at the request of the terminally ill consumer. These decisions may include the termination of medical care, the election of the hospice benefit, or the revocation of election of the hospice benefit on behalf of a terminally ill consumer. Documentation of the authorization must be maintained in the consumer's hospice record.

(GG) "Social worker" means a person registered under Chapter 4757. of the Revised Code to practice as a social worker or independent social worker.

(HH) "Terminally ill" means that a physician has certified that the consumer has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

Replaces: 5101:3-56-01, 5101:3-56- 04.1

Effective: 03/02/2008
R.C. 119.032 review dates: 03/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/16/90, 12/1/91, 4/1/94, 9/26/02, 2/16/04

5160-56-02 Hospice services: eligibility and election requirements.

The purpose of this rule is to outline the criteria that must be met for the consumer to be eligible to enroll in the hospice benefit.

(A) In order to be eligible to elect the hospice benefit under medicaid, the consumer must meet the following criteria:

(1) The consumer must be eligible for medicaid in accordance with Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(2) The consumer must be certified as being terminally ill by his or her attending physician and the hospice medical director or physician member of the interdisciplinary group.

(3) If the consumer is enrolled or becomes enrolled in medicare, the consumer must elect the medicare hospice benefit at the same time that the medicaid hospice benefit is elected in order to assure that medicaid is the secondary payor. If the consumer revokes his or her medicare hospice benefit, the medicaid hospice benefit must be revoked at the same time.

(4) If the consumer has or later obtains third-party coverage of the hospice benefit, the consumer must elect the third-party coverage hospice benefit at the same time that the medicaid hospice benefit is elected in order to assure that medicaid is the secondary payor. If the consumer revokes his or her third-party coverage of the hospice benefit, the medicaid hospice benefit must be revoked at the same time.

(5) If the consumer is a participant in the program of all-inclusive care for the elderly (PACE), the consumer must access hospice services through the PACE site's network of providers.

(6) If the consumer is enrolled in a medicaid managed care plan (MCP), the consumer must access hospice services through the MCP's network of providers.

(7) If the consumer is enrolled in an HCBS waiver program, the consumer may subsequently be enrolled in the hospice benefit. However, if the consumer is enrolled in the hospice benefit and is not also enrolled in an HCBS waiver, the consumer is not subsequently eligible for HCBS waiver program enrollment.

(B) If the consumer is eligible to elect the hospice benefit based on paragraph (A) of this rule, the consumer may elect to receive hospice care during one or more of the election periods as long as the consumer continues to meet the eligibility requirements.

(C) At the time of election of hospice care, the consumer must, in a written statement, elect the hospice benefit with the hospice.

(1) The consumer or representative must acknowledge that he or she has been given a full explanation of the palliative rather than curative nature of hospice care as it relates to the consumer's terminal illness and the provisions and limitations of services as specified in this chapter.

(2) The consumer or representative must sign and date an election form that specifies the type of care and services that may be provided during the course of the illness. The effective date of the election may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement.

(3) When the consumer under age twenty-one voluntarily elects hospice care, he or she does not waive any rights to be provided with, or to have payment made for, services that are related to the treatment of the condition for which a diagnosis of terminal illness has been made, in addition to the hospice palliative care.

(D) For the duration of the election of hospice care, the consumer must waive medicaid services if the services:

(1) Are provided by a hospice other than the hospice designated by the consumer, unless provided under arrangement made by the designated hospice;

(2) Are related to the curative treatment of the terminal condition for which hospice care was elected or a related condition, except for the consumer under age twenty-one; or

(3) Are equivalent to hospice care.

Effective: 02/01/2011
R.C. 119.032 review dates: 03/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 5/15/90, 5/16/90, 12/1/91, 4/1/94, 9/26/02, 1/1/04, 4/1/05, 3/2/08

5160-56-03 Hospice services: discharge requirements.

The purpose of this rule is to detail circumstances in which the consumer would no longer receive the medicaid hospice benefit.

(A) Discharge from hospice care:

(1) The hospice shall discharge the consumer from hospice care when the consumer:

(a) Expires;

(b) No longer meets the enrollment criteria;

(c) No longer terminally ill;

(d) Moves out of the service area;

(e) Enters a non-contracted facility;

(f) Revokes the hospice benefit according to paragraph (B) of this rule;

(g) Transfers to another hospice; or

(h) Compromises the safety of the consumer or the safety of the hospice staff.

(2) The hospice shall complete a written statement of discharge, retain the original for its records and provide the consumer or representative with a copy. The written statement of discharge must clearly state the reason for discharge. A written statement of discharge should not be provided to the consumer's representative when the consumer expires, unless requested from the representative.

(B) Revocation of the election of hospice care:

(1) The consumer receiving the medicaid hospice benefit may choose to revoke the election of hospice care once during each benefit period. Upon revocation of the medicaid hospice benefit, regular medicaid coverage resumes and any rights to additional hospice care coverage through the medicaid program for the remaining days of that benefit period are forfeited.

(2) The hospice must obtain a written statement of revocation signed and dated by the consumer or representative, retain the original for its records, and provide the consumer or the representative with a copy. The written statement of revocation must clearly state the reason for the revocation.

(C) The consumer who voluntarily revoked the hospice benefit, or who has been discharged from hospice care, may elect the benefit at a later date if the consumer qualifies as terminally ill and otherwise meets the requirements of the medicaid hospice benefit as follows:

(1) The consumer who revoked the hospice benefit or who was discharged from the hospice benefit during the initial ninety-day period would enroll in the hospice program in the second ninety-day benefit period; or

(2) The consumer who revoked the hospice benefit or who was discharged from the hospice benefit during the second ninety-day benefit period, or any subsequent sixty-day benefit period, would begin the new enrollment in a new sixty-day benefit period.

(D) Transfer to another hospice:

(1) The consumer or the representative may change the designation of the particular hospice from which hospice care is received once during each benefit period. The change of the designated hospice is not considered a revocation of the election from the period in which it is made.

(2) To change the designated hospice, the consumer or the representative must file, with the hospice from which the consumer has received care and the newly designated hospice, a signed statement the includes the following information:

(a) The name of the hospice from which the consumer has received care;

(b) The name of the hospice from which the consumer plans to receive care; and

(c) The date the change is to be effective.

(E) The consumer who has elected the hospice benefit and decided to revoke, terminate, or transfer his or her hospice benefit must do so on the same effective date for both the third-party covered or medicare hospice benefit and the medicaid hospice benefit.

(F) Any denial or termination of hospice care which is the result of an ODJFS decision shall be subject to the notice and hearing rights contained in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

Replaces: Part of 5101:3-56- 03.1, Part of 5101:3-56- 03.2

Effective: 03/02/2008
R.C. 119.032 review dates: 03/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 5/16/90, 12/1/91, 4/1/94, 9/26/02, 1/1/04

5160-56-03.3 Hospice services: reporting requirements.

(A) The purpose of this rule is to enable recording of the hospice service span of every consumer receiving medicaid hospice services in accordance with Chapter 5101:3-56 of the Administrative Code, even if the consumer is covered by third-party insurance, which includes medicare.

(B) In this rule, the following definitions apply:

(1) "Beginning date of service" means the first date on which a provider delivers hospice services to a consumer.

(2) "Consumer" means a person who:

(a) Is eligible for medicaid;

(b) Has satisfied applicable spenddown; and

(c) Has elected to receive the hospice benefit.

(3) "Consumer election date" means the date on which a consumer elects, in writing, to receive hospice services in accordance with Chapter 5101:3-56 of the Administrative Code.

(4) "Ending date of service" means the date on which a provider stops delivering hospice services to the consumer because of revocation of the medicaid hospice benefit, discharge from the hospice benefit, change by the consumer of the designated hospice, or death of the consumer in accordance with Chapter 5101:3-56 of the Administrative Code.

(5) "Hospice service span" means the period of time, delimited by the beginning date of service and the ending date of service, during which a consumer receives hospice services from a hospice provider in accordance with Chapter 5101:3-56 of the Administrative Code.

(6) "Interactive Voice Response system" or "IVR system" means the telephone-based system maintained by ODJFS that gives authorized entities access to data such as medicaid eligibility, claim status, payment status, prior authorization, drug and procedure codes, and provider information.

(7) "Oral physician certification date" means the date on which an oral physician certification statement that the consumer is terminally ill is obtained in accordance with Chapter 5101:3-56 of the Administrative Code.

(8) "Written physician certification date" means the date on which a written physician certification statement that the consumer is terminally ill is obtained in accordance with Chapter 5101:3-56 of the Administrative Code.

(C) Each provider of hospice services shall enter the following information into the IVR system:

(1) Within thirty days after the beginning date of service, the provider of hospice services shall enter:

(a) The hospice provider number;

(b) The consumer's recipient identification number (also referred to as the medicaid billing number) as shown on the consumer's medicaid card;

(c) The beginning date of service;

(d) Either:

(i) The written physician certification date or

(ii) The oral physician certification date;

(e) The consumer election date; and

(f) At least one but not more than three terminal diagnosis codes for the consumer.

(2) No earlier than the beginning date of service and no later than thirty days after the ending date of service, the provider of hospice services shall enter:

(a) The written physician certification date;

(b) The ending date of service; and

(c) The date of death, if applicable.

(3) No earlier than the beginning date of service and no later than thirty days after the ending date of service, the provider of hospice services may change or update:

(a) The oral physician certification date;

(b) The written physician certification date;

(c) The consumer election date;

(d) Not more than three terminal diagnosis codes for the consumer, so long as at least one diagnosis code remains entered in the IVR system;

(e) The ending date of service; or

(f) The date of death.

(D) The information specified in paragraph (C) of this rule shall be submitted only through the IVR system in accordance with the requirements of that system.

(E) The information specified in paragraph (C) of this rule shall be submitted for all consumers receiving medicaid hospice services, without regard to the payer.

(F) No provider of hospice services shall be entitled to payment on a claim before the information specified in paragraph (C)(1) of this rule has been submitted.

Effective: 09/01/2007
R.C. 119.032 review dates: 09/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021

5160-56-04 Hospice services: provider requirements.

The hospice assumes full responsibility for professional management of the consumer's hospice care in accordance with the hospice conditions of participation. To be eligible to provide medicaid hospice services, a hospice must meet the criteria in paragraphs (A) to () (R) of this rule.

(A) Be eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(B) Meet the medicare guidelines in accordance with 42 C.F.R. part 418 (September 22, 2006).

(C) Be licensed under Ohio law in accordance with Chapter 3712. of the Revised Code by the Ohio department of health.

(D) Comply with all requirements for medicaid providers in Chapter 5101:3-1 of the Administrative Code.

(E) Assure that all hospice employees who provide services are licensed, certified, or registered in accordance with federal and state law.

(F) Not discontinue nor diminish the hospice care it provides to the consumer because of the inability of the consumer to pay or receive medicaid reimbursement for such care pursuant to the medicare requirements at Section 1861 (dd)(2)(D) of the Social Security Act, 42 U.S.C. 1395x(dd)(2)(D) (December 8, 2003).

(G) Inform the county department of job and family services (CDJFS) in writing of any change in the consumer's address.

(H) Arrange for another individual or entity to furnish services to the hospice's consumers in accordance with 42 C.F.R. 418.56 (June 5, 2008) when the hospice cannot provide services to the consumer. This arrangement must include a signed agreement and this agreement must remain on file at the hospice agency.

(I) Facilitate concurrent curative treatment for children under age twenty-one with other medicaid providers to assure that continuity of care is maintained and coordinated to avoid duplication of equivalent services. The provider must document the delineation of the manner in which services and the assessment process are coordinated between medicaid providers.

(J) Provide a copy of the hospice election form that specifies the type of hospice care and services in accordance with rule 5101:3-56-02 of the Administrative Code to other medicaid providers, including providers of concurrent curative treatment.

(K) Provide a copy of the consumer's advance directive to other medicaid providers, including providers of concurrent curative treatment.

(L) Have a signed agreement with the nursing facility, the ICF-MR, the general inpatient facility, and/or the inpatient respite care facility in which the consumer resides and/or receives services. This agreement must remain on file at the hospice agency and contain, at a minimum, the following:

(1) A stipulation that the hospice maintains responsibility for the professional management of the consumer's hospice care;

(2) A delineation of the manner in which contracted services are coordinated and supervised by the hospice;

(3) A delineation of the role of the hospice and the facility in the admissions process, patient/family assessments, and the interdisciplinary group (IDG) conferences;

(4) A stipulation that the facility must have a valid medicaid provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code and accept the payment from the hospice as payment in full as negotiated; and

(5) The terms of the agreement must not violate the medicaid provider agreement as set forth in rule 5101:3-1-17.2 of the Administrative Code and must not violate the consumer's freedom of choice of providers .

(M) The hospice must obtain written certification of terminal illness for each election period:

(1) For the first ninety-day election period, the hospice must obtain, no later than two calendar days after hospice care is initiated, a written physician certification statement signed by the medical director of the hospice or a physician member of the hospice interdisciplinary group (IDG) and the consumer's attending provider;

(2) For subsequent benefit periods, the hospice must obtain a written physician certification statement no later than two calendar days after hospice care is initiated in each of the subsequent benefit periods. The written physician certification statement shall be signed and dated by the hospice medical director or a physician member of the IDG;

(3) If the hospice cannot obtain the written physician certification statement within two calendar days, after a period begins, it must obtain an oral physician certification statement within two calendar days and the written physician certification statement signed and dated prior to submission of a claim;

(4) The hospice must document the oral physician certification statement in the consumer's hospice record and retain the written physician certification statements in the consumer's hospice records;

(5) The physician certification must include a statement that the consumer has a medical prognosis that his or her life expectancy is six months or less if the terminal illness runs it normal course and specific clinical findings and other documentation supporting a life expectancy of six months or less in accordance with 42 C.F.R. 418.22 (August 6, 2009); and

(6) The hospice must also follow these requirements for those consumers who had been previously discharged and subsequently re-elected hospice care.

(N) At the time of election of the hospice care, the hospice must:

(1) Assist the consumer or representative with the election process;

(2) Retain a copy of the election form in the consumer's hospice record; and

(3) On the date of election, provide the consumer or the representative with the following materials and written information:

(a) Conditions of election of the hospice benefit; including

(i) Duration and scope of coverage; and

(ii) Notice of the consumer's responsibility for reporting other insurance and for obtaining health care; and

(iii) Notice of the consumer's responsibility for reporting other providers of concurrent curative treatment for children under age twenty-one; and

(b) Grievance procedures;

(c) Procedures for revocation of the hospice benefit; and

(d) Information regarding advance directives in accordance with Chapter 2133. of the Revised Code and any policies the hospice has regarding the implementation of advance directives.

(i) Each consumer has the right to formulate an advance directive, including a do not resuscitate order; and

(ii) The hospice must maintain the consumer's advance directive in an accessible part of the consumer's current hospice record and include a notation in the consumer's plan of care.

(O) Establish a written plan of care for each consumer prior to providing care, and the care provided to the consumer must be in accordance with the plan. The plan of care must:

(1) Be established and maintained in accordance with the 42 C.F.R. 418.56 (June 5, 2008)

(2) Be established by the attending provider, the medical director or physician designee and the IDG;

(3) Be reviewed and updated, at intervals specified in the plan, by the attending provider, the medical director or physician designee and IDG. These reviews must be documented; and

(4) Include an assessment of the consumer's needs and identification of the services including the management of discomfort and symptom relief. It must state in detail the scope and frequency of services needed to meet the consumer's and family's needs.

(P) Designate a registered nurse to coordinate the implementation of the plan of care for each consumer.

(Q) Assure that care is coordinated for consumers enrolled in an HCBS waiver program. A collaborative effort must occur between the hospice case manager and the waiver case manager or the service and support administrator (SSA) as applicable to maintain a continuum of the overall care provided to the consumer.

(1) Case management of hospice services shall be provided by the hospice case manager in accordance with this chapter;

(2) Case management of waiver services shall be provided by the waiver case manager; and

(3) The hospice must provide services to a waiver consumer in accordance with a comprehensive plan for the concurrent provision of waiver services by waiver and hospice providers. The administrating agency of the waiver or its designee will assist in the coordination of care by:

(a) Reviewing and approving the comprehensive plan for the concurrent provision of waiver services by waiver and hospice providers;

(b) Resolving any issues resulting from the comprehensive plan for the concurrent provision of waiver services by waiver and hospice providers;

(c) Resolving any issues of interpretation when implementing the requirements in this chapter; and

(d) Applying any exceptions to the requirements of this chapter on a case-by-case basis.

(R) Each month, the hospice must identify the consumer as a hospice consumer by labeling the medicaid card with the name of the hospice next to the consumer's name. This is to indicate that hospice care has been elected and a restriction exists on medicaid coverage.

(1) Since the medicaid card lists the names of all medicaid-eligible consumers under a particular case number, the hospice must label the card in such a way as to clearly identify which consumer has elected medicaid hospice care;

(2) The hospice must label the card no later than the eighth of each month to indicate that the consumer is enrolled in the hospice program; or

(3) The hospice must label the card no later than eight days after the consumer has enrolled in the hospice program.

Effective: 02/01/2011
R.C. 119.032 review dates: 03/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 5/1/90, 5/15/90, 5/16/90, 12/1/91, 4/1/94, 9/26/02, 4/1/05, 2/3/05, 3/2/08

5160-56-05 Hospice services: covered services.

For services outlined in this rule to be covered, a certification that the consumer is terminally ill must have been completed, and the hospice service must be reasonable and necessary for the palliation and management of the terminal illness and related conditions. The consumer must elect hospice care, and a plan of care must be established before the services are provided.

A hospice may furnish covered services to consumers who reside in a SNF, NF, ICF-MR, or any residence or facility not certified by medicare or medicaid or at the consumer's home.

When the consumer elects the hospice benefit, the hospice assumes responsibility for the professional management of the consumer's care. Professional management involves the assessment, planning, monitoring, directing and evaluation of the consumer's care across all settings.

(A) The following covered hospice services must be performed by appropriately qualified personnel, and the level of care provided must be based on the consumer's needs:

(1) Core hospice services include the following:

(a) Nursing care;

(b) Medical social services, provided by a social worker under the direction of a physician or attending provider;

(c) Counseling services, provided for the purpose of counseling or training the caregiver and helping the consumer and the family members and/or caregiver with adjusting to the approaching death, including but not limited to:

(i) Dietary;

(ii) Bereavement;

(iii) Spiritual; and

(iv) Additional counseling; and

(d) Physician services.

(2) Non-core services include the following:

(a) Short-term inpatient care that can be accessed on an intermittent, nonroutine, occasional basis for pain control and acute or chronic symptom management and/or respite;

(b) Medical appliances and supplies, including drugs and biologicals;

(c) Home health aide and homemaker services that enable the consumer to carry out the treatment plan;

(d) Physical therapy, occupational therapy, and speech-language pathology provided for symptom control or to enable the consumer to maintain activities of daily living and basic functional skills;

(e) All other medical treatment and diagnostic procedures provided in relation to the terminal condition, when medically indicated; and/or

(f) Transportation services must be provided or arranged for by the hospice:

(i) If there is no other means to transport the consumer, and the ambulance service is the safest way of transportation and it is related to the consumer's condition, the ambulance service becomes a covered hospice service; or

(ii) If the hospice determines that the consumer's need for transportation is for other than receiving care related to the terminal illness, the hospice may make arrangements for the appropriate level or type of transportation and the service may be covered under medicaid in accordance with Chapter 5101:3-24 of the Administrative Code.

(3) Hospice care for consumers residing in a nursing facility or ICF-MR:

(a) The facility has the responsibility to assure that the care outlined in the plan of care is performed by qualified staff and consistent with acceptable professional standards of practice. Those services include:

(i) Performing personal care services;

(ii) Assisting with activities of daily living;

(iii) Administering medication;

(iv) Socializing activities;

(v) Maintaining the cleanliness of the consumer's room; and

(vi) Supervising and assisting in use of durable medical equipment and prescribed therapies; and

(b) The hospice has the responsibility to cover hospice services outlined in paragraphs (A)(1) and (A)(2) of this rule.

(4) Hospice care for consumers enrolled in a home and community based services (HCBS) waiver program:

(a) Waiver services are provided by approved waiver providers if the service is a covered service for that waiver program prior to the election of the hospice benefit; and

(b) The hospice has the responsibility to cover hospice services outlined in paragraphs (A)(1) and (A)(2) of this rule.

(B) For any medicaid services that are unrelated to the treatment of the terminal condition for which hospice care was elected, providers must:

(1) Follow all applicable medicaid authorization policies and procedures; and

(2) Call the hospice before providing any services in order to clarify the consumer's restricted status.

Replaces: Part of 5101:3-56-02, Part of 5101:3-56-03, Part of 5101:3-56- 03.2, Part of 5101:3-56-05, Part of 5101:3-56-06, Part of 5101:3-56- 06.1, Part of 5101:3-56- 06.2

Effective: 03/02/2008
R.C. 119.032 review dates: 03/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 5/15/90, 5/16/90, 12/1/91, 4/1/94, 9/26/02, 1/1/04, 4/1/05

5160-56-06 Hospice services: reimbursement.

ODJFS shall reimburse only the hospice provider directly for the costs of all covered services related to the treatment of the consumer's terminal illness with the exception of reimbursement for physician services that are for direct patient care and, if the consumer is under age twenty-one, with the exception of reimbursement for concurrent curative treatment for the consumer's terminal illness. Physician services for direct patient care will be reimbursed according to paragraph (D) of this rule. Providers billing for concurrent curative treatment will be reimbursed according to paragraph (H) of this rule.

(A) Based on the methodology set forth in 42 C.F.R. 418.302 (August 6, 2009), the medicaid payment for hospice services is made at one of four predetermined rates. Each rate is based on the level of care that is appropriate for the consumer for each day while under the care of the hospice.

Each rate covers all services rendered by the hospice (either directly or under contractual arrangement), the administrative services, the technical services, and the general supervisory activities performed by physicians, and travel expenses and supervision provided by other hospice staff.

The medicaid maximum payment rate for each hospice is set forth in the hospice's provider charge file that is specifically assigned to each participating hospice.

(B) The hospice shall bill ODJFS the appropriate code and unit(s) for the appropriate level of care. The rate paid for the date of service depends on the level of care furnished to the consumer on that day.

(1) Routine home care is covered in accordance with 42 C.F.R. 418.302 (August 6, 2009) Hospice providers must use code T2042 for one unit per day to bill for routine home care.

(2) Continuous care is covered in accordance with 42 C.F.R. 418.302 (August 6, 2009) Hospice providers must use code T2043 for one unit per hour, minimum of eight hours per day to bill for continuous home care.

(3) Inpatient respite care is covered in accordance with 42 C.F.R. 418.302 (August 6, 2009)Hospice providers must use code T2044 for one unit per day to bill for inpatient respite care.

(4) General inpatient care is covered in accordance with 42 C.F.R. 418.302 (August 6, 2009) Hospice providers must use code T2045 for one unit per day to bill for general inpatient care.

(C) When the consumer is a resident of a NF or an ICF-MR, the hospice shall be reimbursed for room and board. This additional per diem amount is reimbursable for routine home care and continuous home care days. Hospice providers shall use code T2046 to bill for room and board. To receive reimbursement, the hospice:

(1) Must bill ODJFS the amount equal to ninety-five per cent of the medicaid NF or the ICF-MR per diem rate as obtained from the NF or the ICF-MR.

(2) Must bill only for days that the consumer is in the NF or ICF-MR overnight and is medicaid eligible.

(3) Can bill for consumers who have elected the hospice benefit under medicare but are medicaid eligible and reside in a medicaid-reimbursed NF or ICF-MR for the room and board.

(D) ODJFS will reimburse separately for physician services involving direct patient care, as follows:

(1) Reimbursement for services provided by physicians who are hospice employees or who are under contractual arrangements with the hospice, unless furnished on a volunteer basis, an administrative basis or a technical service, will not be included in any of the predetermined rates, but will be paid to the hospice separately in accordance with Chapter 5101:3-4 of the Administrative Code.

(2) If the consumer designates an attending physician who is not an employee of the hospice, medicaid will pay the physician directly, if the physician has a valid medicaid provider agreement in accordance with rule 5101:3-1-17.2 of the Administrative Code. Costs for services such as lab or x-rays are not to be included on the attending physician's bill, but are covered in the predetermined rate paid the hospice. Payment for attending physician services is based on current medicaid rules and regulations for physician services as found in Chapter 5101:3-4 of the Administrative Code.

(E) After receipt of the third-party resource, ODJFS may be billed for the balance. For each day the medicaid eligible consumer is enrolled in hospice, the total reimbursement for hospice services cannot exceed the per diem rate for the appropriate code specifying the appropriate level of care.

(F) Medicaid eligible residents of NFs or ICF-MRs who are enrolled in a medicare or medicaid hospice program are not entitled to medicaid-covered bed-hold days. It is the hospice's responsibility to contract with and pay the NF in accordance with rule 5101:3-3-16.4 of the Administrative Code. It is the hospice's responsibility to contract with and pay the ICF-MR in accordance with rule 5101:3-3-16.8 of the Administrative Code.

(G) Pursuant to Section 1861(dd)(2)(A)(iii) of the Social Security Act, 42 U.S.C. 1395x(dd)(2)(A) (iii) (March 30, 2010) there shall be a limitation on reimbursement for inpatient care during the hospice cap period.

(H) For any services related to the terminal illness, providers must bill the hospice provider directly unless the services were for concurrent curative treatment of the terminal illness for consumers under age twenty-one. Providers billing for concurrent curative treatment must comply with, and will only be reimbursed according to, all the requirements for medicaid providers in Chapter 5101:3-1 of the Administrative Code.

Effective: 02/01/2011
R.C. 119.032 review dates: 03/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 5/1/90, 5/15/90, 5/16/90, 12/1/91, 4/1/94, 9/26/02, 1/1/04, 4/1/05, 3/2/08