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 individual to be eligible to enroll in the hospice benefit.

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

(1) The individual must be eligible for medicaid in accordance with Chapters 5160:1-1 to 5160:1-6 of the Administrative Code.

(2) The individual 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 individual is enrolled or becomes enrolled in medicare, the individual 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 individual revokes his or her medicare hospice benefit, the medicaid hospice benefit must be revoked at the same time.

(4) If the individual has or later obtains third-party coverage of the hospice benefit, the individual 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 individual 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 individual is a participant in the program of all-inclusive care for the elderly (PACE), the individual must access hospice services through the PACE site's network of providers.

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

(7) Individuals enrolled in hospice may be enrolled concurrently on a home and community based services (HCBS) waiver.

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

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

(1) The individual 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 individual's terminal illness and the provisions and limitations of services as specified in this chapter.

(2) The individual 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 individual 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 individual must waive medicaid services if the services:

(1) Are provided by a hospice other than the hospice designated by the individual, 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 individual under age twenty-one; or

(3) Are equivalent to hospice care.

Effective: 4/1/2015
Five Year Review (FYR) Dates: 12/19/2014 and 04/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.70
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, 2/1/11