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